LIBRARY OF CONGRESS. 

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UNITED STATES OF AMERICA. 



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BEDSIDE URINE-TESTING. 



ON 

BEDSIDE URINE-TESTING 

A CLINICAL GUIDE TO THE 

OBSERVATION OF URINE IN THE 
COURSE OF WORK. 



GEO. OLIVER, M.D., Lond., 

MEMBER OF THE ROVAL COLLEGE OF PHYSICIANS OF LONDON, ETC. 




I 



J. H. VAIL AND^'tTtf, 



NEW YORK:' 



1885. 



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{I'^f, 



q4 



COPYRIGHT BY 

J. H. VAIL AND CO., 



TROWS 

PRINTING AND BOOKBINDING COMPANY, 

fJEV/ YORK. 



PREFACE. 



^ The aim of this little work is to supply 
^ in the compass of a pocket companion 
the leading data in regard to urinary 
observation, to point out what ought to 
be noticed in the course of work, and 
to indicate the readiest methods of 
testing by which the practical aspects 
of morbid urine may be brought home 
to the senses with the least expenditure 
of time and trouble : in a word, to 
facilitate that important part of clinical 
enquiry — the examination of urine in all 
cases. 

My efforts in this direction having 
proved acceptable in England — this 
American edition being synchronous 
with the third English edition — I bring 
them forward on American soil with the 
hope that they may bear fruit on both 
sides of the Atlantic. 

HavYogate, 

June, 1885, 



CONTENTS. 



INTRODUCTORY. 

Page. 

The aim of bedside urinary testing 13 — 15 

The tests 14 

CHAPTER I. 

The general characters of the urine 16 — 47 

I. On selecting a specimen of urine for 

examination 16 

The urine has deposited 17 

The specimen is turbid 18 

II. The odour 18 

Alkaline urine 18 

Urine containing sugar, cystin, medi- 
cines, &c 19 

III. The consistence 20 

Alkaline purulent urine 20 

Chylous urine 20 

Albuminous urine 20 

IV. The colour 21 

Pale urines 21 

Dark urines 22 

(a) Indican 22 

(6) Melanin 23 

(c) Blood 23 

{d) Bile 24 

[e) Medicines, &c 24 

V. On cloudiness and on deposits 25 

1. Inorganic causes of turbidity 26 

(a) Urates 26 

(6) Phosphates 27 

2. Organic causes of turbidity 28 

(a) Pus. Mucus 29 

The clinical significance 30 

ib) Blood. Hasmaturia. Haemoglobinuria. 31 

The clinical significance 33 

(c) Oil-globules 33 

B 



Page. 

{d) Organisms 34 

3. Deposits 36 

(a) Epithelial 36 

(6) Uric acid 37 

The clinical significance 37 

(c) Light-coloured deposits 38 

Earthy phosphates 39 

Pus 39 

Light-coloured urates 40 

Oxalate of lime. Clinical significance 40 

{d) Dark deposits 42 

Urates 42 

Blood-derived deposit 42 

A tabular view of deposits 43 

On collecting deposits for the microscope... 43 

VL The daily quantity of urine 44 

1. The quantity is excessive 45 

(fl) The increase is temporary 45 

(6) The increase is permanent 45 

2. The quantity is diminished 45 

3. The urine is suppressed 45 

{a) Obstructive suppression 46 

(b) Non-obstructive suppression 46 

4. The nocturnal discharge of urine 47 

CHAPTER n. 

The specific gravity of the urine 48 — 71 

Pocket urinometers 48 

The author's method 48 

The clinical use of specific gravity 5I 

1. Total solids or ' solid urine ' 5^ 

The rule for an approximate calculation ... 53 
Physiological causes of variation. (i)Food. 

(2) Exercise and rest. (3) Body-weight... 54 

Clinical variations 55 

The urinary solids are deficient 55 

{a) Urine normal or sub-normal in 

amount 55 

(6) Urine increased in quantity 59 

The urinary solids are increased 59 

[a) The amount of urine not increased... 59 

(6) The urinary flow is excessive 60 

IL Urea 60 

The daily average mean amount excreted... 62 



Vll 

Page. 
The chief physiological causes of variation. 

(i) Weight.' (2) Diet. (3) Work 63 

The variations of urea in disease 65 

III. Sugar 65 

Rules for calculating the amount when the 
daily discharge of urine (i) exceeds or (2) 

is under 150 ounces 66 

IV. The specific gravity of isolated specimens of 

urine 68 

Maximum solid urine 68 

Minimum solid urine 69 

Practical inferences ...*. 70 

CHAPTER III. 

The reaction of the urine 72 — 81 

The modes of determining the reaction... 72 

Litmus papers 72 

Alkalinized litmus paper. The author's 

method '. 73 

Degrees of acidity 74 

Physiological variation of reaction 75 

The clinical significance of the reaction ... 76 

Urines highly acid 76 

Urines alkaline 80 

CHAPTER IV. 
The forms of proteid substance in the 

urine 82 — 97 

Class I. — Native Proteids 83 

{a) Serum-albumin 83 

ib) Globulin 83 

The clinical significance 85 

Class II. — Derived Proteids 85 

(a) Albuminates. Acid & Alkaline albumin 85 

[b) Peptones. Plemialbumose 87 

The clinical significance of pepton- 
uria 91 

Local inflammation gi 

Lobar pneumonia 91 

General diseases gi 

Disorders of the liver 93 

CHAPTER V. 
Albuminuria : the detedion of albumin by 
aciduiation (citric acid test-paper) and 
heat 98-108 



Vlll 

Page. 
Different modes of applying the test of 

acidulation and heat 98 

Boiling after acidulation 99 

The method 100 

ObjecStion 100 

Acidifying after boiling 105 

Heat not necessary as a routine preliminary 

test 105 

The modes of heating 107 

CHAPTER VI. 

Albuminuria : the detedlion of albumin by 

test-papers iog-130 

The test-papers selec5ted 109 

Mucin no 

The mercuric test-paper 116 

Bodies precipitated 117 

The ferrocyanic test-paper 119 

Bodies precipitated 120 

The modes of testing 121 

Method 1 122 

The nitric acid range 123 

The intermediate range 124 

The heat range 124 

Method n 126 

The methods originally proposed 129 

The test-papers dropped into the urine 129 

The 'contact' method 130 

CHAPTER Vn. 

Albuminuria : quantitative albumin 131-140 

The methods 131 

Method I. — The quantity of albumin ex- 
pressed as a fradtional part of the col- 
umn olurine 132 

The mode of testing 133 

Method n. — The percentage estimation of 

albumin 134 

The mode of testing 134 

The quantitative value of each test- 
paper 139 

The quantity of albumin met with 139 

The daily amount of albumin dis- 
charged 140 



IX 

Page. 
CHAPTER VIII. 
Albuminuria: the clinical significance of 

albumin 141-155 

I. The albuminuria is intermittent 142 

The fadl of intermission is of clinical 

significance 142 

Fundtional albuminuria 142 

The albuminuria of adolescents, of 

bronchocele, &c 143 

II. The albuminuria is persistent 146 

The cause is renal 146 

III. The quantity of albumin 148 

Minimal albuminuria 148 

The quantity of albumin in the different 
forms of renal disease, and of fundtional 
albuminuria 149 

IV. An epitome of the causes of albuminuria 151 

CHAPTER IX. 
Glycosuria : the detedion of glucose by test- 
papers 156-179 

I. The indigo-carmine test-papers 157 

The indigo - carmine test solutions are 
valueless : but the test-paper is available 

for clinical purposes 157 

The readtion 160 

Carbonate of soda papers to be used when 
(i) water hard or (2) urine excessively 

acid 162 

The mode of testing 164 

Confirmation of results by Fehling's 

solution 167 

Experimental testings 168 

Clinical advantages of the indigo-carmine 

test-paper 172 

II. The cupric test-paper 176 

The reaction 177 

Directions 179 

CHAPTER X. 

Glycosuria: Quantitative glucose 180-193 

The indigo-carmine provides quantitative 

information igo 

The mode of testing 183 

Quantitative data 186 

(i) The urine undiluted 186 

(a) The reaction is incomplete „ 186 



X 

Page. 

(Jj) The reaction is complete , i88 

(2) The urine definitely diluted i8g 

Conclusions 192 

CHAPTER XL 
Glycosuria : the clinical significance of 

glucose 194-198 

Glycosuria is not synonymous with dia- 
betes mellitus 194 

The glycosuria is intermittent or temporary 

Digestive or hepatic glycosuria 194 

Diabetes mellitus 197 

CHAPTER Xn. 
Choluria : the detection of biliary derivatives 

in the urine 199-220 

The biliary elements that may appear in 

the urtne 199 

I. The bile-pigment 199 

Visual characters of jaundiced urine 199 

The reaction with a citric test-paper 200 

II. The bile-salts 200 

The urinary derivatives of the biliary salts 200 

The unsatisfactoriness of the clinical tests 
hitherto employed for detecting bile-salts 

in the urine ....'. 201 

The proposed test is founded on a physio- 
logical reaction 204 

The peptone test solution 209 

The reaction 210 

Delicacy of the test : objections 211 

The mode of preliminary testing 215 

Quantitative observation 217 

The peptone test-paper 219 

CHAPTER Xin. 
Choluria : the clinical significance of bile- 
derivatives in the urine 221-252 

The bile-coloured urines of jaundice repre- 
sent but a portion of the urines charged 

with biliary derivatives 221 

I. The bile-pigment 222 

Jaundice 222 

When the urine is pigmented there is 
always an excess of the colourless bile- 
derivatives 222 

II. The bile-salts 223 



Page 
Physiological variations of the renal elimina- 
tion of the bile-salts 223 

Bile-salts in healthy urine indicated by 

the peptone test 223 

Hourly variations 225 

The effects of (i) digestion, (2) exercise, 

(3) alcohol, &c 226 

The clinical significance of the renal elimina- 
tion of biliary salts 232 

Data provided by experiments on animals 232 
The balance between production and elim- 
ination 233 

The bile-salts are increased 235 

1. Jaundice 235 

2. Functional disorders of the liver : 
biliousness, acute biliousness, chronic 
biliousness 236 

3. Diseases of the liver 241 

4. Diseases of the spleen 241 

5. Fever 242 

6. Haemolytic Diseases 242 

(a) Anemia 243 

Leucocythasmia 244 

Hasmoglobinuria 244 

(6) Scurvy 245 

Haemorrhages 245 

The urinary elimination of bile-salts is 

insufficient 245 

1. The production is increased, but the 
elimination is diminished or inefficient 246 

2. The production is not apparently 
excessive, but the kidneys fail to keep 

pace with it 248 

CHAPTER XIV. 
Apparatus 251-256 

I. Graduated test tubes 251 

1. For taking the specific gravity with 

a glass bead 251 

2. For urine-testing 252 

n. Standard opacities 252 

1. For quantitative albumin 253 

2. For the quantitative observation of 
bile-salts 253 

HI. Sundries 253 

1. Nipple pipette 253 

2. Metal clip 253 

IV. Test Papers 254 



INTRODUCTORY, 



The Aim of Bedside Urinai-y 
Testing" is to ascertain, in the ordinary 
course of medical observation, the con- 
dition of the urine : either to detect 
leading pathological states of this excre- 
tion, as immediate aids to diagnosis and 
treatment ; or — as in the majority of 
cases — to definitely eliminate them from 
the clinical view. 

Whether the evidence, thus revealed 
without delay, be positive or negative, it 
may be equalty valuable to the practi- 
tioner at the moment, either by giving 
a turn to his investigation, or by cor- 
recl:ing impressions suggested by other 
data : but, besides thus serving this 
immediate end, it enables the busy man 
to readily w^eed out on the spot the 
important urines for particular investi- 
gation at home, and reduces the liability 

c 



14 INTRODUCTORY. 

to omission of that important part of 
clinical observation — urinary examination 
in all cases. 

The testing of urine should, therefore, 
be rendered as ready and portable at the 
bedside as are other instruments of 
clinical enquiry — such as the thermo- 
meter, the stethescope, &c. To this end 
the following pages are devoted. 

Tlie Tests I propose are in the form 
of test-papers^ : than which I cannot 
conceive of an3'thing more convenient 
for bedside work. The}^ are specially 
fitted for this service b}^ virtue of their 
possessing all the essential qualities which 
should pertain to such tests ; namety, 
trustworthiness, stability, portability, and 
freedom from causticity and other ob- 
jectionable properties. The reader has 
merely to call to mind the miseries of 
nitric acid and of Fehling's solution — the 
urinary cases dilapidated, and articles of 
clothing spoilt by these destructive re- 
agents — in order to realize how unsuitable 
are such caustic tests for pocket use ; and 

iThe strips of chemically charged paper are but vehicles 
for the ready application of the reagents. 



INTRODUCTORY. 



15 



he must then regard with some sense of 
rehef the neat and clean!}- methods 
provided by the test-papers, which can be 
as freeh' handled, and as harmlessl}^ — to 
the fingers and to the tests — as ordinary 
writing paper. 

Then again, no other dr}- preparations 
— such as pellets, powders, &c. — can 
compare with test - papers in readiness 
for use, and in providing in so small a 
compass a series of tests for determining 
several points of clinical importance in 
the examination of urine. 

Moreover, the test-papers, apart from 
ministering to the personal convenience 
of the observer, possess clinical advan- 
tages, such as the handy and time-saving 
methods which they provide for quantita- 
tive estimations. 



CHAPTER I. 



THE GENERAL CHARACTERS OF THE 
URINE. 



I. On Selecting a Specimen of Urine 
FOR Examination. 

Wherever practicable, the urine of the 
whole twenty -four hours should be re- 
served. If this, however, cannot be done, 
the observer should direct the portion 
passed two or three hours after breakfast, 
and that voided on rising, to be kept in 
separate vessels. These specimens will 
provide a fairly good average when mixed 
in equal porportions; and when examined 
separately will afford information as to 
the effects of digestion, and of fasting 
and rest. On no account should the 
observer rely on an examination merely 
of the urine passed in the morning before 
breakfast ; for it may be free from albumin 
or sugar, or nearly so, while the speci- 



Chap. I.] ON SELECTING A SPECIMEN. 17 

mens voided during the day (after meals) 
may contain these constituents in fair 
proportions, or in larger quantities. (See 
pages 144 and 195). 

Tlie Urine lias deposited. — Urine 
reserved for examination has usually 
stood for some hours, and has con- 
sequently allowed any matters in sus- 
pension, that can subside, to settle. The 
observer will often require to examine 
separately the supernatant portion and 
the deposit ; and should, therefore, see 
that the vessel containing them is not 
shaken. Besides, this precaution has 
special reference to testing for albumin 
and bile-acids, when it is highly desirable, 
if not essential for accurate observation, 
to select a transparent portion of the 
urine. 

The nipple-pipette (see chap, xiv.) is a 
most useful article at the bed-side ; for it 
enables the observer to take up a perfectly 
clear specimen of urine — 'perhaps other- 
wise unprocurable — and to examine sepa- 
rately the deposit, or an}^ particular 
portion of it. 



l8 THE ODOUR. [Chap.l. 

The speciiiieii is turbid. — If a 

transparent specimen is not provided, 
and if the turbidity does not clear 
up on adding a citric acid test-paper, or 
with warmth, the observer had best filter 
it ; and, for this purpose, his urinary case 
should be furnished with a few pieces of 
filtering paper — one of which, rolled into 
a cone, and held over the test tube, will, 
in a minute or two, provide a sufficiency 
of transparent urine for albumin, bile-acid 
testing, &c. 

II. The Odour. 

Healthy urine emits a characteristic 
aromatic odour, varying, however, with 
different individuals, and with the degrees 
of concentration of the urine. A strong 
urinous odour is often emitted when the 
percentage of urea — and in fact of the 
total solids — is high. The urine of dys- 
pepsia sometimes emits a sickly odour. 

Alkaline Urine.— The urine, without 
being ammoniacal, often smells of the 
bladder, when feebly acid or alkaline, 
and when slight catarrh of the urinary 



Chap. I.] THE ODOUR. 19 

passages exists. When alkaline from 
fixed alkali, it exhales an odour like that 
of horse's urine. When the urine con- 
tains ammonium carbonate, derived from 
the decomposition of urea, the odour 
becomes * ammoniacal' : and this ma}^ 
be the case when it is voided, or shortly 
afterwards, or after standing some time 
in a warm room. 

Urine emits a 'putrescent' odour, when 
it contains much decomposing organic 
matter, as in destructive disease of the 
bladder, kidneys, &c. 

Siig-ar. — The presence of sugar is often 
attended b}^ a sweet smell, as that of 
new hay, or whey ; and in diabetic coma, 
the urine emits an odour like that of 
chloroform. Saccharine urine in a state of 
fermentation smells like ' turned ' milk. 

Cystiit, — Urine containing cystin at 
first smells like sweet - briar, but speedily 
becomes horribty offensive — emitting 
sulphuretted hydrogen. 

Medicines, &c. — Certain medicines 
(turpentine, copaiba, cubebs, oil of 
sandlewood) and articles of diet (aspara- 



:20 THE CONSISTENCE. [Chap. I. 

gus, garlic) communicate their character- 
istic odours to the urine. 

III. The Consistence. 

Healthy urine is always watery ; but in 
disease, the consistence may be so 
increased, from the presence of mucus or 
muco-pus, as to prevent the urine from 
running into drops — for when poured from 
vessel to vessel it flows out en masse. 

Alkaline Purulent Urine. — If the 
urine be purulent and alkaline there 
will be seen a glutinous mass — con- 
sisting of pus transformed by ammonium 
carbonate into a mucous looking sub- 
stance — which adheres tenaciously to the 
bottom of the vessel. 

Chylous Urine. — In chyluria the con- 
sistence of the urine is increased. (See 

PP- 33. 34)- 
Albuminous Urine. — When albumin 

is present in considerable quantity, though 
the consistence is not obviously, or is 
only slightly increased, the splash of the 
urine is softer and less watery ; and, 
after shaking, the froth remains intadl 



Chap I.] THE COLOUR. 21 

much longer than that of non-albuminous 
urine of the same specific gravity.^ 

IV. The Colour. 

The tint of normal urine ranges from 
straw yellow [urina potus) to golden amber 
[urina sanguinis and tirina cihi) ; the depth 
of colour varying with the concentra- 
tion — abundant and watery urines being 
pale, and diminished discharges of higher 
specific gravity being darker. This rule 
is of pretty general application. 

Pale Urines. — When the urine is pale, 
the observer will bear in mind conditions 
that induce a copious flow ; such as cold 
weather, the free taking of fluids, hysteria 
and other neurotic ailments inducing 
paroxysmal attacks, anaemia and chloro- 
sis, diabetes (mellitus and insipidus), and 
chronic Bright 's disease — especially the 
waxy and granular kidney. The urine of 
women is paler than that of men ; and also 
the urine of persons of feeble general health 
— as during convalescence from acute 

1 "The reader will bear in mind that other than albuminous 
urines may provide a ' stable froth,' such, for example, as 
those well charged with solids — the sp. gr. being over 1020. 



22 THE COLOUR. [Chap. I. 

diseases, &c.— than of the robust. Pale 
urines suggest the absence of fever. 

l>ark Urmes.— On the other hand, 
dark urines are often also concentrated, as 
during warm weather, after active exer- 
cise, in diarrhaea, in fevers, and in dis- 
orders of the liver. Dark urines suggest 
increased tissue-change. 

(a) Iiidicaii. — High coloured and con- 
centrated urines frequently contain a 
large quantity of indican^ — a substance 
which yields free indigo when broken up 
by the per-acid state of the secretion ; 
hence the blue, or violet, or reddish violet, 
or green tint, which appears in such urines 
on standing, and best seen at the surface 
near the sides of the glass vessel con- 
taining them. 

An increase of indican, and the occa- 
sional appearance of free indigo in the 
urine, have been observed in many patho- 
logical conditions : but they are, for the 
most part, such as disturb or delay intes- 
tinal digestion ; e.g.^ obstructive diseases 
of the bowels, dysentery, diarrhaea, typhoid 

1 An excess of indican is also sometimes found in pale urines. 



Chap. I.] THE COLOUR. 2^ 

fever, cirrhosis of the liver, cancer of the 
Hver, cancer of the stomach, peritonitis, 
the reaction of cholera, lymphoma and 
lympho-sarcoma of the abdomen, Addi- 
son's disease, and diseases and derange- 
ments of the entire central and peripheral 
nervous S3^stem.^ Js^ffe has shown that 
indican is greatly increased in obstruction 
of the small intestines and general perito- 
nitis, but onty slightly so in obstruction 
of the large intestine. Senator has ob- 
served an increase in granular kidne3% 
but not in other forms of chronic renal 
disease. 

(h) Melanin. — A black pigment (me- 
lanin) is present in the urine of patients 
suffering from melanotic tumours — espe- 
cially of the liver and the skin — and some- 
times also in ague. In these cases the 
urine ma}^ be of normal colour when 
passed, but becomes black on standing, or 
on the addition of an acid. 

(c) Blood. — When the urine presents a 
smoky hue, the observer will suspect the 

1 This statement summarizes the clinical observations of 
Jatfe, Neftel, Wyss, and Robin. 



2^ THE COLOUR. [Chap. I. 

presence of a small quantity of blood ; 
but when in larger proportion, blood 
communicates a distinctive red colour 
(see p. 31). When the colouring matter 
of the blood corpuscles is present (haemo- 
globinuria or hsematinuria) in large quan- 
tity, the urine is as dark in colour as 
port wine (see p. 32). 

(d) Bile. — Bile is also a cause of dark 
urine. (See p. 199). 

(e) Medicines, &c. — The urine may be 
dark, or even black, when carbolic acid or 
creosote has been taken in large quantity.^ 
Certain vegetable substances, in passing 
out by the urine, communicate their dis- 
tinctive colours ; such as rhubarb, log- 
wood, whortleberries, indigo, madder, &c. 
Santonin gives a yellow bile-like colour to 
acid urine, which moreover, further re- 
sembles biliary urine in staining the linen 
of the patient, but is easily distinguished 
by striking a crimson reaction on adding 

1 Carbolic urine may be pale when voided, but becomes 
dark on exposure to the air. Pyrocatechin (a normal con- 
stituent of horses' urine) in rare cases appears in human 
urine, which is likewise of ordinary colour when passed, but 
darkens on standing, or immediately on adding an alkali. 
(Ebstein and Miiller). 



Chap. I.] CLOUDINESS AND DEPOSITS. 25 

a carbonate of soda test-paper to 60TIX of 
the urine. When chrysophanic acid 
(present in rhubarb and senna leaves) is 
ehminated by alkahne urine, it provides a 
red tint Hke that of blood ; but it differs 
from the latter, by at once paling into 
yellow, when a citric acid test-paper is 
dropped into 6oiix of the urine, and b}^ the 
red colour reappearing on alkalinizing 
the acidified urine by a sodae carb. test- 
paper. 

V. On Cloudiness and on Deposits. 

Healthy urine should be perfectly bright 
and transparent when voided, and should 
remain so — only in the course of a few 
hours permitting a light flocculent cloud 
to fall. The slight loss of clearness of a 
fresh sample should be carefully noted, by 
holding it in a test tube up to the light, 
and shaded by the hand ; and the cause 
of the opacity should be ascertained. The 
degrees of turbidity of course vary — from 
the merest trace to the most dense. 

Urine ma}^ be cloudy when passed, or it 
may become so as it cools. In the latter 



26 INORGANIC TURBIDITY. rchap I. 

case the cloudiness is almost invariably 
due to urates falling out of solution — a 
source of turbidity which does not apply 
to freshly voided urine, unless the urine is 
passed into a cold vessel/ 

The suspended matters, which destroy 
the transparency of urine, may be in- 
organic, or organic, or both. 

I. Inorganic causes of tuvhidity. 

These are for the most part Urates and 
Phosphates. 

[a] lji*ates [amorphous] form the com- 
mon cause of the turbidity of urine ; 
and are distinguished from others by 
quickly vanishing when the urine is merely 
warmed, even by a comparatively low 
degree of heat, e.g. loo^ F. 

As a rule the opacity settles pretty 
quickly and completely; slowly, however, 
if the specific gravity is above normal, ^ or 

1 An exception to this rule is found in the comparatively 
rare cases, in which chrystalline urate of soda falls out of 
solution in the urinary passages — as occasionally happens 
in gouty subjects, and in children. 

•^ Dr. Garrod tells nie, that he lately met with a urine of 
sp. gr. 1054, in which urates fell out of solution, and remained 
as a permanently diffused opacity. 



Chap. I.] INORGANIC TURBIDITY, 27 

the urine contains organic constituents. 
Albuminous, mucous, or bloody urine may 
remain for some time hazy from this cause. 
The colour of the turbidity varies from a 
fawn to a flesh tint (see p. 42). 

It is characteristic of urines which 
deposit lithates, to provide on standing a 
bluish scum on the surface, best seen at 
the sides. Urines that let fall red-tinted 
urates generally contain indican (see p. 
22). 

The clinical significance of a turbidity 
due to amorphous urates ma}^ be ////, as 
when it arises from concentration of the 
urine, and an increase of the acidity : as 
from violent exercise with perspiration, 
from abstinence from fluids, or from a 
bilious attack, or from cold weather; when 
it is onl}^ occasional. When frequent or 
persistent and of a flesh-tint (lateritious) 
there may be fever (inflammatory or not), 
organic disease, or some cause of rapid 
wasting of tissue. 

(h) Phosphates (earthy.) — Every now 
and then the reader will come across a 
urine which when voided is milky, but 



28 ORGANIC TURBIDITY. [Chap. I. 

which clears up complete^ on dropping 
into 6onx of it a citric acid test-paper. In 
such cases the cause of the opacity is due 
to earth}" phosphates, which do not 
dissolve simply because the urine is of an 
alkaline, neutral, or merely of a feebly 
acid reaction. No other form of cloudiness 
is removed by a citric acid test-paper ; 
hence, w^hen it is only in part removed by 
this means, some other source or sources 
of turbidity exist, such as pus, blood, 
bacteria, &c. Phosphatic cloudiness 
(either consisting entirely of earth}" phos- 
phates, or of these along with pus) is 
distinctly white or milky, and is increased 
by heat. 

2. Organic causes of Turbidity, 

The principal organic products that 
impair the clearness of urine are — 

(a) Pus and muco-pus. 

(b) Blood. 

(c) Oil-globules. 

(d) Organisms. 

The loss of transparency due to these 
causes is apparent in the freshly voided 



Chap. I.] ORGANIC TURBIDITY : PUS. 29 

urine ; and differs from cloudiness refer- 
rible to urates and phosphates, by not 
clearing up either with heat, or with a 
citric test-paper. 

(a) Fits, — A very small amount of 
pus suffices to give a haziness to the 
urine held up to the light ; though it is 
true the haze induced may be only slight. 
The presence of pus is pretty certain if 
the fresh urine contains bacteria (see p. 35) 
and a small quantity of albumin. The opa- 
city due to pus differs from that caused 
by blood, in being whitish or greyish. 

If purulent urine contain much mucus 
or albumin, the pus will subside but 
slowly — the turbidit}^ remaining for hours ; 
while, on the other hand, if mucus or 
albumin is present onty in small quantity, 
the subsidence will be rapid, the urine 
being left clear, or perhaps only slightly 
turbid from bacteria (see p. 35.) Purulent 
urines ahvays contain albumin — in propor- 
tion to the amount of pus — in the absence 
of any other source of albumin. 

Miictts, quite apart from pus, is in 
itself not a cause of turbidity; but it 

D 



30 ORGANIC TUDBIDITY : PUS. [Chap. I. 

becomes so, b}^ forming a nidus, as 
it were, for the deposition of cellular 
elements — pus, blood, &c. — and of amor- 
phous urates and phosphates. When 
present in excess, mucus communicates a 
glairy or glutinous character to the urine 
throughout, and does not specially pro- 
vide a deposit. The faint cloud that 
forms in the body of the urine shortly 
after being voided, and then slowly sub- 
sides, is mucus along with epithelium 
derived from the genito-urinary passages. 
It is larger in women, the vagina pro- 
viding mucus and cellular elements (epi- 
thelium and pus). 

The Clinical significance of Pus. — Pus is 
the common source of the small quantities 
of albumin so frequently encountered in 
urine, especially in that of women ; the 
slightest vaginal discharge, even in 
children, leading to the contamination. 

An inflammatory irritation of any por- 
tion of the mucous lining of the urinary 
passages creates a purulent exudation 
which mixes with the urine, e.g., of the 
urethra (gonorrhaea and gouty urethritis), 



Chap. I.] ORGANIC TURBIDITY : BLOOD. 31 

bladder (cystitis from any cause), pelvis 
of the kidney (pyelitis). 

The observer will also bear in mind the 
bursting of an abscess into the urinary pas- 
sages, ^.^., perineal, peri-vesical, peri-renal. 

(h) Blood. — The presence of blood, 
even in very small quantity, impairs the 
transparency of the urine, and generally 
communicates a distinctive colour: a red- 
dish tinge, if the reaction of the urine is 
alkaline, or the quantity of blood is 
more than ^ of a per cent. ; and a dull 
smoky appearance, if the urine is acid, 
or the amount of blood is small. When 
the blood is of renal origin, the urine is 
usually smoky, and lets fall a dirty brown- 
ish deposit ; but when otherwise, the urine 
is more distinctly red, and clots may be 
detected. 

Urine containing blood is always albu- 
minous ; and when coagulated the clot is 
brown-tinted. 

If the urine is muddy and dark — even 
as dark as porter or port wine, but devoid of 
the clearness of jaundiced urine of that 
depth of colour — and has let fall an abund- 



32 ORGANIC TURBIDITY : BLOOD, [chap. I. 

ant chocolate - looking deposit, and is, 
moreover, highly albuminous — the albu- 
min coagulating into brownish instead of 
the ordinar}^ white masses on boiling, and 
on separating leaving the urine as dark as 
before — in all probability the observer is 
dealing with a case of hcBmoglohinuria — a 
paroxysmal disease in which the red-cor- 
puscles are dissolved, and the liberated 
haemoglobin thus passes out with the urine. 
There are lesser degrees of this ailment, in 
which, during the paroxysms, the urine may 
be merety dusky, providing a smaller de- 
posit — of the same character however — and 
containing proportionately less albumin. 

If the observer wishes to examine a 
suspicious urine at home for blood by the 
guaiacum test, he will find a slip of white 
blotting paper, dipped in the urine and 
dried, a convenient vehicle : then it \A\\ 
only be necessary to let fall a drop of the 
tincture of guaiacum on it, followed 
by a drop or two of ozonic ether or of 
spirits of turpentine ; when the char- 
acteristic blue colour will appear if blood 
is present. 



Chap. I.] OIL GLOBULES. 33 

The clinical significance of blood. — Blood 
may proceed from any part of the urinary 
apparatus — from the tubuli uriniferi to the 
urethra. The principal causes of urinary 
haemorrhage may be classified thus : 

Traumatic. External injury. Renal calculi. Diminu- 
tive concretions in tubuli uriniferi. 

Morbid Growths y &c. Cancer. Tubercle. Parasites. 
Fungoid growth (bladder). Varicose veins 
(bladder). 

Renal Congestion^ &c. Passive (heart disease). 
Active (acute nephritis, effects of turpentine, 
cantharides) . Chronic Bright's disease (blood 
in microscopic proportions as a rule). 

Symptomatic. Haemoglobinuria. Purpura. Scurvy. 
Malaria. Eruptive fevers, &c. 

Vicarious. Menstrual. 

(c) Oil-globules. — Urine containing 

particles or globules of fatty matter 

presents a milky appearance, always 

contains albumin, and often blood (then 

the urine has a slight rose tint), peptones, 

and sugar. Chyluria is the principal 

clinical example of this kind of urine ; 

the characteristic feature of it is a 

fibrinous clot, which rises to the surface, 

forming there a white or pinkish jelly-like 

layer, and leaving the urine below still 



34 ORGANIC TURBIDITY: [Chap. I. 

turbid, though less so than when voided ; 
and the consistence of the urine is in- 
creased in proportion to the number of 
fatt}^ molecules. Sometimes in this ail- 
ment the fat globules are absent ; but 
there is fibrin (as indicated by the forma- 
tion of a coagulum like that of calf's foot 
or currant jelly) and also albumin ; in 
other words the urine is lymphous not 
chylous'^. 

(d) Org-anisMis. — The principal micro- 
scopic organisms that give rise to 
turbidity of fresh or recently voided urine 
are Bacteria and Spermatazoids. 

The common rod-bacterium, or Bac- 
terium Termo, or Vibrio, is frequently 
encountered in large numbers in urine 
just voided — as well as, of course, in stale 
urine. 

According to my observation, it is much 
more frequently met w4th in the fresh 
urine of women than in that of men ; a 
difference which appears to be traceable 
to the prevalence of these active vitriones 



1 See Urinary and Renal Diseases, by Wm. Roberts, M.D. 

1885. 



Chap. I.] ORGANISMS. 35 

in the vaginal secretions, and the migra- 
tion of them through the short urethra into 
the bladder, where they may swarm in the 
newly secreted urine. 

The slight opacity induced by these 
organisms is characterized by two 
features : 

(i) It does not settle, however long the 
urine is set aside : the upper portion 
remaining as fully charged with the 
bacteria as the lower. 

(2) When the urine, contained in a test 
tube, and shaded by the hand, &c., is held 
up to the light and agitated, it is seen for 
the moment to become traversed through- 
out by fine silky waves, which interlace. 
Whenever I have observed this peculiar 
waviness in fresh urine I have invariably 
found by the microscope either these rod- 
bacteria or spermatazoids ; but in the 
latter case the opacity settles. 

The urine in this form of bacteruria 
generally contains a trace of albumin from 
purulent contamination ; the reaction of it 
is either only sHghtly acid, neutral, or 
somewhat alkaline ; and it is more disposed 



36 DEPOSITS: EPITHELIAL. [Chap. I. 

than normal urine to undergo ammoniacal 
fermentation. 

The presence of the Bacterium Termo 
does not, as a rule, set up any marked 
local symptoms. Sometimes, however, I 
have noted slight irritability of the 
bladder, and a diposition to nocturnal 
micturition. Of course when cystitis 
existed — and this bacterium is often to be 
detected in the fresh urine of cystitis — 
there w^ere the usual symptoms.^ 

3. Deposits. 

(a) Epitlielial. — Epithelial debris col- 
lects in the light flocculent cloud that falls 
from all urines : it is more abundant in 
women than in men ; and in all cases fine 
flak}^ particles are to be observed. In men 
who have had gonorrhaea, or who are 
affected by some prostatic irritation, there 
are seen to float through the freshly voided 

1 Dr. Wm. Roberts has described a form, or rather two 
forms of bacteruria, differing from jthat associated with the 
Bacterium Termo, mainly in three respects : no unusual dis- 
position on the part of the urine to undergo decomposition ; 
complete subsidence of the organisms in the urine ; and 
rather prominent local symptoms — dysuria, and the like. 
{On Urinary and Renal Diseases, 1885, p.p. 176 — 183.) 



Chap. I.] DEPOSITS: URIC ACID. 37 

urine many small stringy-looking flocculi, 
which eventually gather in the light 
mucous-like deposit. 

(b) Uric Acid — The only sediment re- 
cognizable by the naked eye as separate 
grains or crystals of a reddish brown 
colour is uric acid, in the form of ' red 
sand ' or ' cayenne pepper grains,' or fine 
* red specs.' This deposit is observed on 
the sides of the glass as well as at the 
bottom : and the particles vary greatly in 
point of size, not only in different urines, 
but in the same sample — from mere dust 
to coarse sand ; when in a fine state of 
division, uric acid resembles lateritious 
urates in appearance, but is readily dis- 
tinguished b}^ warmth failing to dissolve 
it. Urines that deposit uric acid are 
always acid — often per- acid. 

The clinical significance of Uric Acid de- 
posits, — The precipitation of uric acid sand 
is definitely pathological, if it takes place 
before the urine is voided — the uric acid 
crystals being discharged with the urine 
— or as the urine cools. It implies acidity 
of the urine, and, as a rule, a lower density 



38 DEPOSITS: URIC ACID. [Chap. I. 

than obtains when urates fall : hence, it 
often happens that urates separate first, 
and uric acid afterwards. The deposition 
of urates is determined mainly b}^ concen- 
tration and temperature along with an 
acid reaction : while that of free uric acid 
is less affected by temperature than by 
acidity and a reduced density. Uric acid 
deposits are apt to occur when the action 
of the skin is checked, as in cold weather, 
or when there exists extensive disease of 
the skin (eczema, psoriasis) or when the 
tegument is harsh and dry ; and when the 
diet is, for the individual requirements, 
too rich in nitrogenous elements. They 
often precede gtycosuria, or alternate with 
the appearance of sugar. A showier of 
uric acid crystals is apt to follow a gouty 
attack. 

All other deposits — so far as the naked 
eye can recognize — are amorphous. In 
colour they vary greatly : being either 
white or greyish, fawn, pink, red, or dark 
brown. 

(^) Lig-lit-Coloiu'ed Deposits.— When 
white or greyish, they are likely to consist 



Chap. I.] DEPOSITS : PHOSPHATES, PUS. 39 

of earthy phosphates, or pus, or both : and 
this presumption will be confirmed, if the 
reaction of the urine is alkaline, neutral 
or only faintly acid ; and, furthermore, if 
there be an iridescent scum on the sur- 
face. If, on transferring some of the 
sediment to the test tube, the opacity 
completely vanishes on adding a citric 
test-paper, it is due to phosphates only : 
if it is not thus clarified, it may arise 
from pus or possibly ttrates of a light colour : 
and if it is only in part cleared up by the 
acid, it may be ascribed to phosphates along 
with pus, A phosphatic opacity is always 
increased by heat. It implies either a 
lowering of the acidity of the urine to 
the verge of neutrality, or an alkaline re- 
action : and does not signify an increased 
elimination of phosphates. 

A trace of albumin in the supernatent 
urine provides presumptive evidence in 
favour of the deposit containing pus : 
and this is confirmed by the failure of 
warmth to reduce the turbidity. If the 
deposit adheres tenaciously to the bottom 
of the vessel — when the urine will be am- 



40 DEPOSITS : URATES, OXALATE, [chap. I- 

moniacal — and, from its great viscidity, 
can be drawn out into ropes, its purulent 
nature is unquestionable. When, however, 
the urine is acid, pus is not thus trans- 
formed into a tenacious mucous-like mass. 

Light coloured tirates may fall from urines 
of comparatively low specific gravity. 

Oxalate of lime also provides a light 
coloured deposit. Dr. Wm. Roberts thus 
aptly describes the naked-eye characters 
of it as it appears in the urine-glass. 
" The sides of the glass are seen to be 
traversed by ver}^ numerous fine lines, run- 
ning in bands, transversely or obliquely, 
giving an appearance as if the glass 
were finely scratched. This appear- 
ance is due to the crystallization of the 
oxalate on the fine lines or inequalities 
left after cleaning the glass by towelling. 
The subsided portion is equally peculiar, 
it consists of two parts — a soft pale-grey 
mucous-looking sediment occupying the 
bottom of the vessel, and overlying this a 
snow-white denser layer with an undu- 
lating but sharply limited surface. The 
only other substance which crystallizes in 



Chap. I.] DEPOSITS : OXALATE OF LIME. 41 

lines on the sides of the glass is uric acid ; 
this is easily discriminated by the greater 
coarseness of the lines, and their more or 
less brown colour."^ The clinical signifi- 
cance of oxalate of lime, when it forms a 
copious and persistent deposit, is a some- 
what disputed matter. There is no doubt 
that certain vegetables increase it : such 
as onions, tomatoes, rhubarb, turnips, &c. ; 
but, apart from this dietetic source, there 
are certain well defined pathogenic con- 
ditions that favour the deposit : such 
as, 

(i) Fermentative dyspepsia: fatty acids 
(butyric, acetic, lactic) being gener- 
ated that impede the development 
of the blood discs, and thereby lower 
the oxygen-carrying power of the 
blood — oxidation halting at oxalate 
instead of proceeding to carbonate. 
(2) Insufficient supply of oxygen from 
some impediment to respiration 
(emphysema, &c.,) or from impu- 
rity of the atmosphere, or the food 
(especially sugar and starch) in 

1 op. cit., pp. 80, 81. 



42 DEPOSITS: URATES, BLOOD. [Chap. I. 

excess of the oxidizing power. In 
a word, impeded metamorphism 
from deficient oxidation. 

(3) Depressed nerve-tone. 

(dj Bark: I>ei»ositi$. — Deposits of a 
darker hue — from fawn to chocolate- 
brown — are mostly due either to urates, 
or to a blood product. 

Sediments consisting of tirates vary in 
colour from light brown to a pronounced 
flesh tint ; and they always fall from 
urines distinctly acid — generally per- 
acid. The depth of colour is in a general 
way proportionate to the specific gravity ; 
being fawn-tinted when the specific 
gravity is from 1016 to 1018, and pink- 
tinted when the degrees are higher. 
Warnrith always clears up an opacity due 
to urates. 

Deposits of a dirty brown or chocolate 
colour, or bright red, and especially when 
consisting of clots, are probably blood- 
derived: and this suspicion will be con- 
firmed or negatived by detecting albumin 
in the supernatent urine, or failing to do so ; 
and by the colour of the urine (see p. 31). 



Chap. I.] 



DEPOSITS. 



43 



The foregoing characters of urinary 
deposits, as they appear to the naked-eye, 
may be thus epitomized : — 



Dissolves 
Urates. 

From fawn to pink tinted. 



^Oxalate of Lime. 

Deposits in fine lines on urine glass ; 
and below snow white, and sharply 
defined. 



Uric Acid. 

Brown crystals. 

Pus. 

Greyish. 



Blood. 

Brown or red. Urine smokey 
or bright red. 



Urine 
albu- 



Increases 
Phosphates. 

White. Dissolve up completely with 
citric test-paper. 



Oil collecting" ^ deposit for exe^siaiii- 
ation at iioiiie toy tSie microscope. — 

It is frequently advisable to obtain the 
sediment derived from the urine of 
24 hours : as for example, when, in 
searching for casts in a doubtful case, 



44 'rHE DAILY QUANTITY. [Chap. I. 

a specimen of the urine passed during 
the day has not provided positive in- 
formation. In many urines, especially 
when the amount of albumin of renal 
origin is small, very few casts are present : 
or the}^ are absent from one discharge of 
urine but appear in another. Then the 
examination of the whole deposit of the 
day's urine will enable the observer to 
decide the matter with more certainty, 
and with greater facility, than that of 
several ordinary specimens. The whole 24 
hours' urine should be allowed to settle, 
and the clear part poured off from the 
sediment contained in the last six or eight 
ounces, which should be reserved for the 
microscopical examination. 

VI. The Daily Quantity of Urine. 

The average daily discharge may be 
roughly estimated at fift}^ ounces, and the 
ordinary variations pertaining to the same 
person, as well as to different individuals, 
may be gauged at one third above or 
below the mean amount. 



Chap. L] THE DAILY QUANTITY. 45 

The quantity is excessive. 

(a) The increase is temporary. — 

This may arise from cold, nervous excite- 
ment, a fit of hysteria, an asthmatic 
attack, copious drinks, or diuretics. 

{h) The increase is persistent. — As 

in diabetes melhtus and insipidus, and in 
the course of waxy and granular (the 
cirrhotic) kidney. 

The qiiantity is diminished. 

Reduction of the urinary flow occurs 
when fluids are taken habitually in small 
quantity ; when the skin and lungs are 
unusually active, as in hot weather — 
especially when exercise is taken — and in 
fever; when the kidneys are embarrassed, 
as in congestion from heart disease, in 
acute inflammation, in sub-acute inflam- 
mation in the course of Bright's disease, in 
some forms of renal disease throughout, 
and towards the close in all varieties ; 
when vomiting or diarrhaea is persistent, 
as in cholera ; and when the bowel is 
obstructed — as in acute strangulation 

£ 



45 THE DAILY QUANTITY. [Chap. I. 

high up. The urine is also greatly reduced 
in quantity in most hepatic diseases and 
disorders, and alwa3^s in cirrhosis of the 

liver. 

The urine is suppressed. 

Failure of the urine to appear in the 
bladder may arise from either mechanical 
obstruction (obstructive suppression) or 
from organic disease or obscure disorder 
— neurotic or vascular — of the kidneys 
(non-obstructive suppression). 

[a) Obstructive suppression : as from 
a calculus impacted in the ureter — there 
being onty one kidney (congenital defect) 
or onty one workable kidney ; vesical 
tumour closing up the ureters, &c. 

{b) Non-otostructive suppression: as 
in acute nephritis — especially the form 
that follows scarlatina ; and in chronic 
Bright 's disease — at the close ; in cholera 
and yellow fever ; in fever and inflamma- 
tions generally — when intense ; in shock — 
especially from cathetering and other 
operations on the urethra ; and in hysteria.^ 

1 See Charcot's Diseases of the Nervous System. New Syd. 
Soc. 



Chap. I.] THE DAILY QUANTITY. 47 

The nocUirnal discharge of urine. 

When the kidneys are healthy a much 
larger proportionate quantity of urine is 
excreted during the day, than during the 
night. The practitioner turns this physio- 
logical fact to good clinical account, when 
he suspects chronic renal mischief or dia- 
betes, as soon as he discovers an increase 
of the quantity of urine discharged in 
the night. In some forms or stages of 
atrophic degeneration of the kidneys 
(cirrhotic especially) the nocturnal rise 
of urine is very considerable ; and when- 
ever it occurs, it calls for enquiry. 



CHAPTER II. 



THE SPECIFIC GRAVITY OF THE URINE 



Pocket Urmometers. — Some time 
ago I made a good many observations on 
the working of the small pocket urino- 
meters in general use, in order to test the 
readings they provide — how far they are 
reliable. I found these little instruments 
of precision merely so in name and 
appearance : for they were liable to a 
wide range of error — at least from five 
to seven degrees. I, therefore, regard 
them for clinical purposes as valueless 
and misleading. 

The Autlior's Method.^ — For taking 
the specific gravity — and especially at the 
bedside-I greatly prefer a glass bead accu- 
rately representing 1008, (ch. xiv). This is 
dropped into the graduated test-tube (ch. 
xiv) and the urine is added to the lowest 

1 The idea of obtaining the specific gravity by dilution was 
suggested to me by Dr. S. C. Smith, of Halifax, in the course 
of a discussion on my method for quantitative albumin at the 
Leeds Medico Chirurgical Society. 



Chap. II.] THE SPECIFIC GRA VITY. 49 

mark : if the specific gravity is below 
1008, the bead at once falls to the bottom 
of the tube ; but if — as in nearly all urines 
— it is higher than this figure, the bead 
floats up to the surface — the rapidity of 
the motion being greater as the specific 
gravity is higher. If now, the observer 
adds water, little by little, and with some 
force, so as to mix well with the urine, he 
will reach a stage in the dilution when 
the bead will cease to rise ; and, after 
inverting the tube on the thumb, so as to 
secure a uniform mixture, it will either 
still fail to ascend, and will remain sus- 
pended at any part of the column — now 
of the same specific weight as that of the 
bead : or it may yet slowly rise ; in which 
case, a little further dilution is needed to 
bring it to a stationary condition. When 
suspension of the bead has been thus 
secured, the figure on the right hand side 
which marks the height of the column, 
indicates the specific gravity : then the 
observer will find the bead is so delicately 
poised, that merely one drop of water will 
determine its fall. 



50 THE SPECIFIC GRAVITY, [chap. II. 

If the bead still floats when the limit 
(1024) provided by the tube is reached, 
the diluted urine is poured out, or re- 
moved by the pipette, until the column 
stands at 24 on the left hand side ; and 
water is added as before, and when the 
bead ceases to rise, the figure to the left 
expresses the specific gravity. 

A little practice will soon enable the 
observer so to regulate the successive 
additions of water, as to determine the 
specific gravity with nicety without over- 
stepping the limit ; and in this he will be 
mainly guided by the rapidity or slowness 
of the rise of the bead projected down- 
wards by each dilution — the slow ascent 
of course implying an approach to the 
point when the reading should be taken. ^ 

1 If the specific gravity is to be determined with accuracy 
a correction for temperature must be made ; for all instru- 
ments are graduated at 60° F., and every 7 degrees of deviation 
from this temperature causes an error of one degree — to be 
subtracted from, or added to the registered figure according 
as the thermometer stands below or above 60°. To ensure 
this precision for observation at home, I use a urinometric 
arrangement made for me by Mr. Hawksley, 357, Oxford 
Street, consisting of a large bead (1005) and a graduated 
tube, fitted with a thermometer, which enables me to make 
the necessary correction at once. In frosty weather the 
observer will do well, in using the pocket tube and bead, 
to subtract 2°. 



Chap. II.] THE SPECIFIC GRAVITY. 51 

Advantag-es. — This mode of observa- 
tion of the density of urine will serve 
the practitioner, not only on the score of 
portability, but in being helpful in furnish- 
ing reliable results under circumstances 
which prevent accurate determination by 
ordinary urinometers : as, for instance, 
when the sample of urine procurable is 
too small — as so frequently happens — or 
being recently voided, is so warm as to 
give, on immediate examination, a mis- 
leading density. In the latter case the 
requisite addition of water is a useful 
corrective. 

The Clinical use of Specific Gravity. 

The density of the urine provides useful 
clinical information as to the amount of 
solids discharged. It is a ready and time- 
saving quantitative method, which yields 
data sufficiently approximate to be useful 
in current clinical observation. Inasmuch 
as the urine passed at different times of 
the twenty-four hours varies very much 
in total contents — the specific gravity in 
the same individual often ranging from 



52 THE SOLID URINE. [Chap. 11. 

1008 to 1028 — the observer should, if 
possible, always take the density of the 
whole day's urine, and also note the 
quantity discharged. 

The specific gravity of the twent3^-four 
hours' urine may yield approximate in- 
formation as to the daily amounts of total 
solids, of urea, and of sugar. 

I. The total solids, or 'solid urine,'' 

A healthy man of from 20 to 40 years 
of age, and of about 10 stones (140 lb.) in 
weight, should excrete in the twenty-four 
hours as much urinary solids as will give 
a specific gravity of 1020 to 50 ounces of 
urine. If he discharges this average daily 
quantity of urine, it should contain a little 
over 4 per cent, of solids, or nearly 20 
grains to the ounce ; or in all about 1000 
grains. 

20 gr. X50 oz. — 1000. 

The percentage of the solids oscillates 
from hour to hour, and from day to day, 
on either side of the mean (4 p.c.) and the 
specific gravity is in keeping with it. 



Chap. II.] THE SOLID URINE. 53 

When the specific gravity of the twenty- 
four hours' urine is lower than the average, 
the quantity is generally larger ; and when 
higher, as a rule, the urine diminishes. 
So that in the calculation of the daily dis- 
charge of the urinary solids, the specific 
gravity alone, or the twenty-four hours' 
urine alone, is insufficient : they must be 
taken together. 

The Rule for an Approximate 
Calculation. — A good and simple work- 
ing rule is to multiply the last two figures 
of the specific gravity by the number of 
ounces of the urine : and the product will 
approximately represent in grains the 
* solid urine ' discharged in twenty-four 
hours. For example, sp. gr. loig, urine 
55 ounces : 

19X55 = 1045 grains.^ 

Before, however, comparing the solids 
thus calculated from, data afforded by 
disease with the standard amount, the 

1 A deduction of 5 per cent, provides a nearer approach to 
truth, e.g. 

19x55 = 1045—50 = 995 

But the simplicity of the rule is thus somewhat impaired ; and 
without this correction it suffices for all practical purposes. 



54 THE SOLID URINE. [Chap. II. 

observer should allow not less than one 
fifth, above or below it, as consistent with 
the variations of health. For example, 
the following urines fall well outside these 
limits. 

(i) Specific gravit}^ 1017 : twenty-four 
hours' urine 40 oz. 

17X40=680. 

(2) Specific gravity 1022 : twenty-four 
hours' urine 70 oz. 

22x70=1540. 

Pliysiolog^ical Causes of Variatioii# 
— On referring the estimations of the 
solids of particular urines to this standard 
(from 800 to 1200 grains) the observer, in 
order to qualify his opinion, should bear 
in mind the principal causes which 
determine the persistent excretion of 
different amounts of solid urine in the 
healthy ; such as the following : 

(i) Food. Meals always augment the 
solids ; and the habit of full-feeding 
favours a permanent increase, and spare- 
eating the reverse. 

(2) Exercise and Rest, An active life 
(physical and mental) tends to increase 



Chap. II.] THE SOLID URINE. 55 

the solids, while inactivity of body or mind 
disposes to a reduction. 

(3) Body-weight. This is a leading cause 
of the individual variations in the daily 
amounts of urinary solids. The heavy, as 

a rule, excrete more than the light. 
Observation has shown that in adults each 
pound of the body- weight yields generally 
from 7 to 8 grains of solid urine, and, 
therefore, each stone (141b) about 100 
grains.^ In woman an equivalent weight 
provides rather less urinary solids than in 
men. Children under seven years of age 
excrete in proportion to their weight, 
nearly twice as much solids as adults ; but, 
by the sixteenth to the eighteenth year, 
the relative amount settles down to that 
which obtains in after years. 

In estimating the daily discharge of 
urinary solids, the qualifying influence of 
weight should always be taken into 
account — providing, however, that the 
patient is not too fat or bony : for fat and 
bone are tissues that contribute but little 
to the urinary excreta. The body- weight 

1 See The Composition of the Urine by E. A. Parker, M.D. 



56 URINARY SOLIDS DEFICIENT, chap. II.] 

may sometimes decide the position of 
urines containing solids on the borders of 
the average amount, or ma}^ emphasize 
what appears to be the sHghter departures. 
For example, when a man not unduly 
bon}^ or fat, weighing 12 stones, is com- 
puted to eliminate 850 grains^ (sp. gr. 
1017 and urine 50 oz.) his urinary excre- 
tion may be said to be below par — for it 
is at least one third less than the amount 
(1200 grs.) calculated from his weight. 

Clinical Fariatioms, — The daily 
amount of solid urine is a valuable index 
of the tissue- changes — their rapidity or 
degree, and their disorder — and of the 
integrity of the kidneys. The morbid 
variations are such as fall below the 
physiological limits, or exceed them. 

The Urinary Solids are deficient. 

The urine itself may be normal in 
quantity, or it may be scanty, or excessive. 

{a) The amount of Urine is normal or sub- 
normal. — Without recognizable organic 
disease of the kidneys, or of other organs, 

1 Or corrected by deducting 5 p.c. — 808. 



Chap. II.] URINARY SOLIDS DEFICIENT. 57 

the solid urine may be small, though the 
urinary flow is not reduced, or is only 
somewhat below the average. The habits 
of life may account for the failure, such 
as small eating, sedentariness, &c ; or 
there may be a deficiency of muscular 
tissue — a tissue that yields a larger pro- 
portionate amount of urinary excreta 
than others ; and, perhaps, a relative 
excess of bone and fat ; or the defective 
excretion of urinary waste may indicate a 
slow and failing metamorphosis of tissue 
generally, as when nutrition is taking on 
the senile type prematurely, or when 
there is a lull in nutritive activity from 
some depressing influence. The condi- 
tion described by Sir Andrew Clarke as 
' renal inadequacy ' ib of this character, 
for it appears to be the expression of 
defective metabolism of the tissues 
rather than of renal failure. In forming 
an opinion of the reduction of the urinary 
excreta in such cases, the observer will 
. bear in mind that after fifty years of age 
a gradual falling ofl" takes place ; a reduc- 
tion of from ID to 2Q per cent, should be 



58 URINARY SOLIDS DEFICIENT. [Chap. II. 

allowed from fifty to sixty, and at least 
25 or 30 per cent, after sixty. Then 
again, a fall in urinary solids marks the 
enfeebled metabolism in anaemia and 
hydraemia, and in the cachexia of syphilis, 
of cancer, and of chronic alcoholism. 
Imperfect action of the liver probably 
also reduces the solid urine, as when the 
hepatic function is merely debilitated or 
sluggish, or when there is organic disease, 
such as cancer, abscess, &c. 

The elimination of solids is retarded 
when the kidneys are crippled by disease. 
In acute nephritis (as after scarlatina, 
&c.,) in the intercurrent inflammatory 
conditions of chronic renal disease, some- 
times at the close of Bright's disease, and 
in hyperaemia of the kidneys (cardiac 
disease, emplysema dilating the right 
heart, &c.,) the urine itself is likewise 
reduced in quantity. In the early stage 
of renal disease, and even during the 
course of insidious chronic renal disease 
(as in the gouty and in the tubercular 
kidney) the daily amount of urine may be 
normal or sub-normal. 



Chap. II.] URINARY SOLIDS INCREASED. 59 

{b) The Urine is increased in quantity. The 
total solid constituents may be diminished 
while the flow of urine is excessive. This 
condition of persistent watery urine 
(hydraemia) is witnessed in diabetes insi- 
pidus, and in the cirrhotic kidney. In 
the waxy (amyloid) kidney, the discharge 
of the urine is also increased, but the 
daily elimination of the solids is not, as a 
rule, diminished. 

The Urinary solids are increased. 

As with the diminution, so with the 
increment of the solid urine, the discharge 
of the urine itself may not be augmented, 
or it may be excessive. 

[a) The amount of the urine is not increased. 
In fever, as a rule, while the per centage 
of the total solids is raised, the total 
daily amount is not. But there may 
be an absolute as well as relative in- 
crease in certain forms of dyspepsia,^ and 
in lithsemia. 

1 Dr. Fuller recorded this fact {''On excess of urea in the 
urine in certain forms of dyspepsia and nervousness.'^ Medico- 
Chirurg., Trans., Vol. 51, 1868.) in some cases of dyspepsia 
characterised by langour, inaptitude for exertion, extreme 
nervousness and apprehension, flatulence, acidity, &c., but 
without loss of flesh or of the appearance of health. 



6o THE DENSITY : UREA. [Chap II. 

(h) The unnary flow is excessive. The 
augmented excretion of solids is usually 
accompanied by an increased discharge of 
urine : as in diabetes mellitus (persis- 
tent elimination of glucose in excessive 
quantity), phosphaturia (the ' phosphatic 
diabetes ' of Tessier, in which the phos- 
phates are thrown out in enormously 
increased proportion), and in azoturia 
(marked by excessive excretion of urea). 
Phosphatic diabetes and azoturia are rare 
forms of polyuria, which probably depend 
on augmented metabolism of the tissues 
from disturbed innervation. 

II. Urea. 
Urea forms very nearly one half of the 
total solids of healthy urine. In disease this 
proportion is sometimes considerably dis- 
turbed,^ but not so frequently as might be 
supposed. I have now so often confirmed 
the general agreement, between the amount 
suggested by the specific gravity and that 
of the urea actually determined, that I 
have come to regard gravimetric observa- 

1 As in fever, diabetes mellitus, and renal disease. 



Chap.IL] THE DENSITY : UREA. 6l 

tion as very useful, in providing at least 
a good approximation : and especially 
as suggesting in the preliminary enquiry 
the selection of particular urines for the 
ureometer. 

It is pretty well known, that even 
when urea has been accurately deter- 
mined, the observer is scarcely justified, 
as a rule, in concluding there is a de- 
crease or an increase, unless the varia- 
tion falls outside one-fifth of the standard 
mean — below or above it. Inasmuch, 
therefore, as the specific gravity will, in 
the absence of glucose, provide data that 
are, in a general way, commensurate with 
this wide margin of deviation, it should be 
of some use in contributing at least an 
approximation towards a reliable calcula- 
tion of the amount of urea discharged — at 
any rate in the ordinary run of cases. The 
following examples taken from my case- 
book, illustrate the general agreement 
which usually obtains between the amount 
of urea calculated from the specific gravity, 
and that determined by the ureometer. 
The majority of the cases were renal. 

V 



62 THE DENSITY : UREA. [Chap. 11. 

Daily amount of urea in grains. 

Calculated. Determined. 

320 301 

300 259 

205 210 

184 197 

586 597 

440 444 

445 431- 

460 470 

368 344 

360 340 

507 525 

451 497 

The approximate calculation of the 

daily excretion of urea may be made by 

halving the total solids.^ (See page 53.) 

The Daily Averag^e mean Amount 
Excreted. — Each stone of body -weight 
(apart from excess of fat or bone) yields 

1 The amount in grains per ounce may be estimated by 
subtracting the ratio of i degree in 10 from the specific 
gravity, then taking the last two figures and dividing them 
by 2, e.g, 

1016—1,6=1014.4. 
14.4^-2=7.2 grains per oz. 
The per centagc may be calculated by dividing the number 
of grains per ounce by 4.36, e.g. 

7.2-^4.36=1.65. 



[Chap. II. THE DENSITY: UREA. 63 

about 50 grains. A healthy man, weight 
10 stones, and age from 20 to 40, should 
excrete about 500 grains, with variations 
up to 100 grains, less or more. The total 
amount should be reduced by about 10 
grains per stone in women, and should be 
doubled in children under seven years of 
age. A reduction should be made for age 
beyond forty ; 5 per cent, from forty to 
fifty ; and ten per cent, between fifty and 
sixty ; and after sixty the decrease is 
proportionately greater. 

The Chief Physiological Causes 
of Variation to be kept in mind are : — 

(a) Increase from large eating, es- 
pecially of nitrogenous (animal) food ; 
copious drinking of water, particularly 
when warm ; exercise, and full vigour and 
development of the muscles. 

(h) Decrease from fasting or spare 
feeding, and the diet largely non-nitro- 
genous (starch and sugar) and vegetable ; 
reduction or deprivation of water ; alco- 
holic drinks (beer, strong wines) tea and 
coffee ; indolence of mind and body, and 
lowered nutritive condition of the muscles* 



64 THE DENSITY : UREA. [Chap. II. 

The principal factors of the variations 
of urea in different individuals are weight, 
diet, and work (vital, mechanical, and 
mental). The causes of deviation in the 
individual — diet and wo7'k — continually 
present themselves to the clinical observer, 
who soon comes to estimate, in a general 
way, their influence. For example, when 
after prescribing a non-nitrogenous diet 
and rest to ease the renal work, he is 
careful to attribute the immediate fall in 
urea to the right cause — to his directions 
rather than to an increasing incompetency 
of the kidneys. By rest and diet the 
daily discharge of urea can be reduced by 
at least two-fifths, so that, for example, 
500 grains excreted b}^ a person taking 
ordinary exercise, will fall to about 300 
grains, when he rests in bed, and takes 
merely such light food as will prevent 
waste of tissue. The diminished amount 
eliminated when the body is at rest, and 
preserved from loss of weight by a diet 
chiefly non-nitrogenous, nearly represents 
that portion of urea which is derived from 
the vital processes — about three-fifths of 



Chap. II.] THE DENSITY: SUGAR. 65 

the total discharge: the remainder — nearly 
two-fifths — being contributed by work.^ 
Ttie Variations of Urea in I>i8ea!§e 

were for the most part sketched when 
the total solids were under review ; for the 
causes that determine an increase (even 
in glycosuria) or a decrease of the solid 
urine, also produce a rise or fall in the 
amount of urea. This rule, however, fails 
in the case of fever, w^hich augments the 
urea without increasing the urinary solids 
as a whole. 

III. Sugar, 

When the urine is glycosuric, there is 
generally a rise in the specific gravity 
above the normal range^ : and, as a rule, 
the higher density is in a general way 
proportionate to the amount of sugar. 
Inasmuch as, in different cases, or even in 
the same case, there is no exact agreement 
between them, the specific gravity can 

1 See a very instructive essay On the Natural Constants 
of the Urine of Man, by the Rev. Prof. Haughton, F.R.S. 
Dublin. 

2 The exceptions to this rule should, however, be kept in 
mind ; for occasionally a urine is met with containing sugar, 
though of average specific gravity. 



66 THE DENSITY: SUGAR. [Chap. II. 

only furnish a rough estimate : but it is 
one, nevertheless, that is suggestive in the 
preliminary enquiry. The principal source 
of the discrepanc}" is due to the varying 
proportions of the non-saccharine solids. 

The discharge of Urine exceeds 
150 Ounces in Twenty^Fonr Hours. 
— When the urine is voided in large 
quantity (e.g. over 150 oz. in twenty-four 
hours) the precentage of the urinary solids 
falls to such an insignificant degree, that 
the secretion is practically little more than 
a solution of glucose, and the specific 
gravity becomes a fairly accurate guage 
of the amount of sugar — each degree 
over the thousand being nearly equivalent 
to one grain per ounce. ^ 

The I>aily Flo^v of Urine is under 
150 Ounces. — When the discharge of 
urine is less copious, the variations ^ 
between the specific gravity and the 
amount of sugar become ver}^ consider- 
able. For example : eight cases of 



1 Experiment shows that the last two figures of the specific 
gravity of a solution of glucose nearly correspond fa,irly well 
with the number of grains per ounce : e.g. a 5 per cent, solution 
(21.8 grains per ounce) gives 1021. 



Chap. II.] THE DENSITY: SUGAR. 67 

excessive flow (over 150 ounces) with an 
average specific gravity of 1041, elimi- 
nated 42 grains of glucose to the ounce ; 
and ten cases, in which the discharge 
of urine was less, with an average 
density of 1035 excreted only 25 grains 
per ounce. 

When the daily amount of the urine is 
below 150 ounces, an average deduction 
for non-saccharine solids may, however, 
be made, which considerably reduces the 
discrepancy between the specific gravity 
and the amount of glucose. The rule for 
this correction is — to subtract from 1020, 
I degree for every 5 ounces of urine 
over the average discharge of 50 oz. (see 
p. 44) ; and then to deduct the figure thus 
obtained from the specific gravity of the 
urine ; when the remainder will roughly 
represent the glucose in grains per ounce : 
for example, urine go ounces, specific 
gravity 1039 ; 

1020 — 8 (5x8^=40 oz. over 5o) = ioi2. 

1039 — 1012 = 27 grains per ounce. 

It is true the quantity thus calculated is 

but a general approximation : but even as 



68 THE DENSITY OF [Chap. II. 

such it may be sometimes useful ; as when 
the busy practitioner cannot avail himself 
of one of the accurate quantitative 
methods. 

IV. The Specific Gravity of isolated specimens 
of Urine, 

When the twenty-four hours' urine is 
not available, and observation must be 
made on isolated samples, the specific 
gravity may still be clinically useful : 
providing the observer is on his guard 
against the principal disturbing influences 
— notably meals and sleep. 

Maximum §oiicl Urinee— He will spe- 
cially bear in mind, that the urine con- 
tains its maximum charge of solids from 
three to four hours after a meal ; when it, 
therefore, attains its highest range of 
specific gravity, from 1020 to even 1027, 
eg,, from 12 to I when breakfast is taken 
at 8-30 or g, and from 5 to 6 when the 
patient dines at 2. This physiological 
fact tells on the clinical conclusions to be 
drawn from the urine in two ways. In 
the first place, a falling off of the specific 



Chap IL] ISOLATED SAMPLES. 69 

gravity below 1020 at these periods — 
when it should reach its maxima — affords 
greater presumptive evidence of renal 
failure — especially w^hen albumin is pre- 
sent in even small quantity — than does 
the urine voided at other times. And, 
secondly, if the specific gravity is high, 
the detection of traces of albumin, &c., is 
of somewhat less clinical significance 
than when it is low or below the normal 
mean ; allowance should, therefore, be 
made for the concentrated condition of 
the urine. 

l^Iiiiimiiiii ^olid Urine.— On the other 
hand, the observer requires to be cautious 
in drawing conclusions from his examina- 
tion of urines voided at times, when the 
least proportions of solids are discharged : 
as for example, during the night, and on 
rising ;^ an hour or so after a copious 
draught ; and when the patient is nervous 
and flurried by the medical enquiry into 
his case, or by some other cause. Then 

1 The urine of a person in health passed either during the 
night, or on rising, contains, as a rule, but one half of the 
solids discharged four hours after a full meal — breakfast or 
dinner — and especially the latter. 



70 THE DENSITY OF [Chap. II. 

the specific gravity is low, and no clinical 
significance can be attached to it on that 
account. But the observer will bear in 
mind that the discovery of a trace of 
albumin, bile-salts, &c., in a urine of 
small density — e.g., 1008 or loio — is, as 
a rule, more suggestive of something 
wrong, than when a similar minimal 
quantity is detected in a more concen- 
trated urine ; and it should then 
direct the clinical enquiry towards 
the kidneys, liver, &c. The observer 
should remember there is one property of 
the urine which does not maintain a 
uniform relation with the different degrees 
of concentration, viz., the reaction ; for 
when there is a maximum of solid urine — 
four hours after a meal — there is a 
minimum acidity, and when the solids are 
reduced, as during the night and before 
breakfast, the acidity is increased (see 

P- 75)- 

Practical inferences.— Bearing these 
facts in mind, the observer, confined to the 
examination of isolated samples of urine, 
will draw the followino^ conclusions : — 



Chap. II.] ISOLATED SAMPLES. 71 

(a) He will select, if possible, the most 
concentrated specimen — that voided four 
hours after a full meal — as well as that 
passed before breakfast ; and he will not 
rely solety on the latter. 

(h) In comparing the results of treat- 
ment, he will submit to examination, as 
far as practicable, only such samples as are 
of similar specific gravity, and discharged 
at the same hour. 



CHAPTER III, 



THE REACTION OF THE URINE. 



Modes of determining the reaction, 

JAtunw^ papers. — Blue and red litmus 
papers — the former for determining acidity 
and the latter for alkalinity — have been 
found the most convenient for all clinical 
purposes. Litmus of neutral tint — serving 
for both acidity and alkalinity — is unfor- 
tunately apt to pass from exposure into 
the red variety. The degrees of acidity 
or of alkalinit}^ are generally judged by 
the slightness or sharpness of the change 
of colour, and a neutral reaction does not 
affect either test-paper. 

Red litmus paper not only detects 
alkalescence, but it enables the observer 
to distinguish when the alkalinity is due 
to a fixed alkali (potash or soda), or to the 



Chap. III.] ALKALINE LITMUS PAPER. 73 

volatile one (ammonial : for, in the former 
case the blue colour remains after the 
paper has been thoroughly dried, while in 
the latter it vanishes. 

Alkaliiiized lL.itmii§ Paper. — Ordin- 
ary blue litmus paper, while deciding 
definitely enough whether a urine is acid 
or not, provides but the most general evi- 
dence of the various degrees of acidity : 
for, nearly all urines — though differing 
greatly in respect to their charge of free 
acid and of acid salts — react with it very 
much alike. Clinical requirements fre- 
quently demand a definite scale of acidities 
— in the place of the loose general impres- 
sions afforded by simple litmus paper — 
and I find that such can be provided, by 
charging test-papers with a uniform 
quantity of alkali — carbonate of soda — 
along with the litmus. These alkalinized 
litmus test-papers have afforded me ver}' 
satisfactory and definite results, and I 
recommend the following as the best 
mode of using them. 

One of the test-papers is dropped into 
6oT)X of w^ater ; after a little vigorous 



74 DEGREES OF ACIDITY. [Chap. III. 

shaking with the thumb over the mouth 
of the tube, a blue emulsion is produced ; 
into this urine, in stages of lonx at a time, 
is run ; and after each addition the con- 
tents of the tube are shaken up. The 
reaction is at an end, when the blue 
colour acquires a reddish tinge — a transi- 
tion tint : then it will be definitely 
replaced by red, on adding a further loirt 
of the urine. 

Degrees of Acidity. — This mode of 
observation enables the practitioner to 
recognize definitely four degrees of 
acidity ; namely : 

Super-acid, when lom of the urine are required. 
Per-acid, ,, 20 m ,, ,, 

Acid, ,, 30m ,, ,, 

Sub-acid, ,, 40m ,, *> 

For example : when the urine has an 

average degree of acidity, the addition of 

the first and of the second iottl merely 

reduces, and does not tinge by red the 

blue colour ; but on adding the third lonx 

a reddish blue tint appears ; and lonx 

more strike up a distinct red colour.^ 

1 Artificial light is not favourable for the observation of 
these colour reactions. 



Chap. III.3 PHYSIOLOGICAL VARIATIONS. 75 

This method is ready and practical; 
and it certainly provides more precise and 
useful results than can be obtained from 
ordinary litmus paper. 

Physiological Variations of Reaction. 

During the twent3^-four hours the urine 
undergoes a remarkable series of fluctu- 
ations in its reaction. The normal urine 
of the whole day provides a mean of 
acidity, which at certain periods is greatly 
exalted, and at others depressed : it is 
raised before meals, and during the hours 
of sleep ; and is lowered for several hours 
by feeding. Even in health the urine may 
become neutral, or even quite alkaline 
two or three hours after meals. The 
wave of reduced acidity that follows the 
meals has been aptly termed the ' alkaline 
tide': which generall}^ sets in an hour 
after breakfast and two hours after dinner, 
retaining its maximum strength^ for an 

1 In most urines the ' height ' of the alkaline tide is marked 
by milkiness of the urine when voided — the earthy phos- 
phates falling out of solution from deficiency of acid : the 
urine being either sub-acid, neutral, or alkaline. This occurs 
more particularly three or four hours after the largest meal 
of the day, e.g., after dinner rather than after breakfast. 



76 ACID URINES. Chap. III.] 

hour in the former case, and for at least 
two hours in the latter, and then turns, 
and is replaced by the * acid wave,' which 
either immediately preceds the following 
meal,^ or developes during the interval of 
fasting and rest. (See diagram.) 

The ' acid wave ' that follows the ' alka- 
line tide ' is in proportion to the intensity 
of the latter : in other words, the wave of 
depressed acidity is remotely followed by 
a corresponding wave of exalted acidity. 
Animal food has a greater power to in- 
crease this remote effedl than vegetable 
food. 

Clinical Significance of the Reaction, 

In disease we are mainly concerned 
with high acidit}^ and with alkalinity. 

Urines Mglily acid. — Whatever con- 
centrates the urine increases the acidity 
(see p. 59). Hence a febrile movement 
attended by perspiration raises the 
acidity: e.g., rheumatic fever. In dys- 

1 I have repeatedly observed, that the degrees of acidity 
noted before dinner (at 2 p.m.) and evening meal (at 8), 
increase, for an hour or so after these meals : but I have not 
detected the same fact after breakfast. (See diagram.) 



The hourly fluctii ations of the reactioTi of the 
Drine as determin e d hy the jUkalinized Litmus Paper . 



tii^ ^-' k by ^ i^ 

r III i- 


^ 
1 


; * : 




•v)> 


'■ \ \ '■ y 


JBreaMisi. 


»g 


"t 


H.-^i^i 


o 


1 5 


■"^ i 


s 


: > 


k M 


rj 


\ 


> 






O : 


-§ 




s^; Dtrrner, 


ro 


i 1 ■ Y 1 


g: 


u^U^ \ 


►^ 


y^\ • 


01 


n^>j 


Ci 


i'^^S... : 


M 


|Sy^ J^irenm^Meal . 


CD 


: >< 


CO 




s 


M < : 


(— t 


i M \J 


?o 


Soars of Sleep. 





Chap. III.] ACID URINES. yg 

pepsia — especially of the acid type — the 
urine is frequently highly acid, while at 
other times it is neutral or even alkaline ; 
this variability of the reaction is a marked 
feature in all derangements of the diges- 
tive organs — and is even more pronounced 
in children than in adults.^ In diabetes 
mellitus the urine is generally per-acid. 

Per -acid, and especially super -acid 
urines deposit urates as they cool — even 
sometimes this will happen at the moment 
they are discharged into a cold vessel. A 
urine may, however, be per-acid, or even 
super-acid, though remaining transparent 
in the cold. The observer should bear 
in mind, that the urine voided before 
breakfast, is generally more acid than 
that passed at other times. The sense 
of smell sometimes suggests the presence 
of an excess of acid. 

Inasmuch as the higher ranges of the 
acidity of the urine are, in all probability, 



1 In these cases, just as the reaction alternates from 
decided acidity to alkalinity, so the nature of the deposits 
varies: the acid samples becoming turbid from amorphous 
urates, and letting fall crystals of uric acid, while the 
alkaline ones are milky from earthy phosphates. 



8o ALKALINE URINES. [Chap. HI. 

salutary, in being one of the principal 
channels by which the due alkalinity of 
the blood is maintained, the practitioner 
should test the strength and duration of 
the acid tides, whenever there is a dis- 
position to the development of diseases 
depending on sub - alkalinity : such as 
rheumatism and gout ; and, should he 
detect a failure in the aojd waves, either 
in intensity, or in the time they should 
run, he may take the hint which physi- 
ology affords, and widen the intervals 
between the meals. The best urines for 
determining this matter are those passed 
in the early morning, immediately before 
dinner, and within two hours afterwards : 
and the observer will bear in mind that 
the first should be super-acid, the second 
acid, and the third per-acid. 

Urines Alkaline. — Alkalinity is due 
either to a salt of a fixed alkali (carbonate 
or phosphate of potash or soda), or to the 
carbonate cf the volatile alkali — ammonia. 
I have already referred to the distinctive 
odours ol the two kinds of alkaline urine 
(see p. 19) : and the different reactions 



Chap III.] ALKALINE URINES. 8l 

with red litmus — fixed in the one case, 
and fugitive in the other (see p. 72). 
Fresh urine, alkahne from fixed alkaHs, 
is always secreted as such — and is, there- 
fore, the expression of the blood-state — 
and does not irritate the mucous mem- 
brance of the urinary passages : but, on 
the other hand, that which is ammoniacal, 
is scarcely ever — if ever — furnished in 
that condition by the kidneys, but is 
derived from decomposition of urea in 
the bladder, and is, moreover, most irri- 
tant to the mucous lining. All alkaline 
urines are turbid from the precipitation 
of earthy phosphates ; and often from pus. 

Alkalinity of the urine from Jixed alkalis 
is often found, whenever there is general 
debility and anaemia from almost any 
cause : when bile-derivatives pass freely 
into the blood : and when there is dys- 
pepsia in which acid fermentation is a 
prominent feature. 

Urine ammoniacal when voided, is generally 
associated with cystitis, and, therefore, 
with all the causes of this disease. 



CHAPTER IV. 



THE FORMS OF PROTEID SUBSTANCE 
IN THE URINE. 



The properties of albuminous matter in 
the urine vary according to its chemical 
form and combination. Different proteid 
bodies have been isolated and studied ; 
but they are all closely allied as members 
of the same family group. 

Heat divides them into two classes, 
according as it does, or does not, coagulate 
them. Those that are precipitated by 
heat are the ' native ' proteids of the 
blood — i.e. natural to the blood ; serum- 
alhiimin and globulin. Those that are 
unaffected by heat, are ' derived ' proteids 
— i.e. transformations of the ' native ' 
proteids ; such as the albuminates — com- 
binations of albumin with an acid or an 
alkali — peptones and hemi-albumose. 



Chap. IV.] NATIVE PROTEIDS. 83 

Class I. Native Proteids. 
Coagulable by heat : the coagulum being 
permanent at the boihng point. 

[a) 8erum-all»uiiim. — From the cHni- 
cal stand-point serum-albumin is the most 
important proteid that appears in the 
urine. It is necessary that we should be 
able to definitely determine its presence 
or absence ; and, when present, to distin- 
guish it from all other modifications of 
albumin, which indeed are met with but 
seldom, and which occupy a clinical posi- 
tion quite subsidiary. The modes of bed- 
side testing, which appear to me to 
reliably secure this aim, and an outline of 
the clinical bearings of serum-albumin in 
the urine are reserved for Chapters v., 
vi., and vii. 

ih) CJlobulin. — The globulin of the 
blood-serum is chemically allied to serum- 
albumin, and when it appears in the urine 
— as it frequently does — it is always, or 
nearly always,^ associated with albumin. 
Heat cannot distinguish it from serum- 

1 Werner reports a case of nephritis, due to cold in a boy of 
5J years, in which the urine contained globulin only {Deutsche 
Med. Wochensch Band 46, 1883). 



84 GLOBULIN, [Chap. IV. 

albumin, for it coagulates both : and it is 
equally affected by other albumin precipi- 
tants. But it differs from albumin in being 
insoluble in pure water, or in water con- 
taining salt in less than a certain small 
proportion — though soluble enough in the 
urine which is sufficiently saline. When, 
therefore, the salinity of a urine, con- 
taining globulin in quantity, is reduced 
by diluting it largely with water, the 
globulin falls out of solution, and furnishes 
a milky appearance. This fact provides 
a ready clinical test for detecting this 
proteid in albuminous urine. ^ The milki- 
ness of the globulin-reaction with water 
vanishes on dropping into it either a citric 
or a soda test-paper. When globulin is 
dissolved in a slight excess of an acid, or 
of an alkali, it is at once converted into 
acid-albumin, or alkali-albumin respec- 
tively : and it is one of the probable sources 
of these forms of albumin in the urine. 

1 This observation can, of course, only be made properly, 
when the urine is perfectly transparent: so that filtration 
should be resorted to if there is any opacity. The urine may 
either be dropped into the water contained in the test tube, 
or about 20m of the urine are gradually diluted until the 
milkiness appears. 



Chap. IV.] DERIVED PROTEIDS. 85 

Globulin has been frequently detected 
in acute nephritis, and in Bright's disease 
— in the early acute stage (blood in the 
urine), and in advanced renal disease, 
when the patient has become very anaemic. 
It is most abundant in waxy kidney 
(Senator). It is said to be freely present 
in catarrh of the bladder.^ 

Class II. Derived Proteids. 

Non-coagulable by heat ; or, if coagu- 
lable at a certain temperature, completely 
clearing up below the boiling point — 
the vanishing precipitate reappearing as 
a diffused opacity as the urine cools 
(hemi-albumose). 

(a) AlMoffiinates. — Albumin readily 
combines with an acid or an alkali, and 
the definite compounds thus formed are 
no longer coagulable by heat. The urine 
not unfrequentty presents conditions which 
favour such combinations, such as the 
presence of a fixed alkali, or an unusual 
charge of free acid, e.g., lacftic, oxalic, 

1 A Guide to the Practical Examination of the Urine, by 
James Tyson, M.D., 1884, p. 47. 



86 A LB UMINA TES. [Chap. IV. 

acetic. The reader will call to mind, 
that of the blood - derived albumins, 
globulin is ver}^ prone to pass into the 
form of an acid, or an alkaline albumi- 
nate. 

Though acid and alkali-albumin are 
not as such precipitated by heat — which 
may, therefore, overlook them — when the 
former is converted into ordinar}^ albumin 
by an alkali, and the latter by an acid, 
coagulation at once takes place. To en- 
sure this result, neutralization is best 
e£fe(5led in the following manner, by the 
acid and alkaline test-papers : the urine 
is boiled, and while hot, a test-paper 
(citric for alkali-albumin, and soda for 
acid-albumin) is dropped in, when a 
streak of albuminous opacity will follow 
the paper as it sinks to the bottom. 

Both these modifications of albumin are 
thrown down by the ferroc3^anic and mer- 
curic test-papers, and the precipitate of the 
latter does not dissolve up with heat, as 
does that derived from peptones. There- 
fore, in a urine unaifec1:ed by heat, a pre- 
cipitate, insoluble with heat, induced by 



Chap. IV.] PEPTONES. 87 

the mercuric test-paper — or by a solution 
provided by it — suggests one of the 
modified albumins — acid-albumin or syn- 
tonin, or alkali-albumin or casein.^ 

(b) Peptones.— In 18522 Mialhe asserted 
that digested albumin (the peptone of 
Lehmann) may appear in the urine ; and 
since then the observation has been 
confirmed by several trustworthy clinical 
observers. Chemists have distinguished 
several forms of the soluble and diffusible 
proteids which pass under the generic 
term ' peptones ' : but little is known 
as to whether one or several varieties 
of them may be met with in the 
urine. 

Several well defined chemical properties 
separate these ' peptoid ' bodies as a 
family group from the blood-derived albu- 
mins — globulin and serum-albumin ; such 
as : — 

1 In testing for albumin by heat, acid and alkaline albumin 
may be unwittingly produced by the impurity of the test 
tube — as when a small quantity of nitric acid, or of Fehling's 
solution remains after using these reagents, then the heat test 
may completely fail in precipitating albumin, even though 
present in large quantity. 

■2 L' Union Medicate, 1852. 



88 PEPTONES. [Chap. IV. 

(i) Non-precipitation by heat,^ or by 
the ferrocyanic test-paper.^ 

(2) Precipitation by the mercuric test- 
paper : the precipitate dissolving with 
heat, and re-appearing as a diffused 
opacity as the urine cools — no longer 
falling into coagula in the cold; and, on 
re-heating, vanishing again, without 
breaking up into coagula, as on the first 
application of heat. 3 

Inasmuch as peptone often appears in 
the urine along with serum- albumin, it is 
clinically important to know how to 
readily distinguish between the two bodies 
occurring together. I find the following 

1 The body called hemi-albumose, identified as the pecu- 
liar form of albumin discovered by Bence Jones in a case 
of osteo-malacia, is however, partially coagulated by heat, 
but the opacity vanishes as the temperature is further raised, 
and re-appears as the urine cools. The properties of this 
proteid point to its being a transition product between albu- 
min and peptone. It is precepitated by the ferrocyanic test. 

2 I have observed that a peptone, added to urine, or to a 
solution of salt, is not precipitated by the ferrocyanic test- 
paper ; but, when merely dissolved in water, it is freely preci- 
pitated. This fact may account for the opposing statements 
of observers in reference to the behaviour of this test with 
peptones. It does not precipitate them in urine. (Senator). 

3 I find that heat does not clear up the precipitate 
induced by the mercuric test-paper, or by the picric solution, 
when the peptone is dissolved merely in water ; but it does so 
on adding salt ; the presence of the salt in urine is, therefore, 
necessary for the complete removal of the opacity. 



Chap. IV.] PEPTONES. 89 

a good and easy procedure in the pre- 
liminary search : — 

The proteid matter contained in 60 
minims of urine is precipitated by the 
mercuric test-paper — two reagent papers 
being used if the amount of albuminous 
matter be pretty large. On applying 
heat, the opacity gathers up into dense 
coagula, which mass together, and either 
float up bodily like clotted cream to the 
surface, or fall ; leaving the urine trans- 
parent, or only slightly opaque, from a 
trace of albumin that will not coagulate 
by heat. After boiling, the test tube is 
filled with warm water to slight overflow- 
ing, so as to float out the scum of 
coagulated albumin, and, after adding 
a pinch of salt, is set aside. In 
the course of five minutes the larger 
particles and coagula will have subsided, 
leaving the column merely milky. The 
upper inch is now boiled, so as to test 
whether the opacity be due solely to 
albumin, or to albumin along with a 
peptoid body ; for, if it remains un- 
impaired, it is due to a blood-derived 



90 t-- jio. lanpuIT. 

albumin^, but If the portioii heated becomes 
decidedly less opaque than that below it^ 
or if it clears up entirely, the presence 
of the soluble form of albumin may be 
strongly suspected ; and i^ after the 
addition of another reagent paper — so as 
:: ir : :::r : rTain there is an excess of 
: i : i r : r : : . le amount of blood- 
: T T 5 ent — the opacity still 

i t5 : 5 with hei: :he 



Chap. IV.] PEPTOX URIA . 9I 

TJie Clinical Significatice of Peptonuria. 

Those^ who have worked at peptonuria, 
and have, therefore, had special and large 
experience, are distinctly of opinion that 
it is alwa3^s a morbid fact : and one. more- 
over, independent of albuminuria — for 
the}" found large quantities of peptones 
in the urine v^-iihout a trace of albumin. 
and albumin without peptones. - 

Peptonuria has been detected in various 
local and gerxerai diseases; such as the 
following: — 

(i) Local inflammatory affections : especially 
those tending to the formation of pus. 
Not, however, in all local inflammations, 
even when suppurative, does peptonuria 
occur ; for it is often absent in the 
chronic forms. Though it is not a posi- 
tivety differentiating sign between simple 
and purulent exudation, it affords, in 

somewhat impaired by its failing to afford in j^i. ii M:e i jirize 
quantitatiTe information — the reaction being i::u: :l-f E£.~e 
with mere traces as with large quantities — an i : y :;i ^ n : : iji= : 
bile-acids, which react the same as peptones i.zt znrr. zi e: 
with in excess. (See p. 204). 

1 Sncb as Freridis, Schnltzen, Reiss, Hofzi t : : r r ] i : zz er . 
Jaksch, Poehl, Gerhart, Eichwald, Pecri, azi I in _:;;r 

2 In some of Gerhart' 5 ca=5= rrr.izzrii :"ever. pre- 
ceded albominuiia. 



g:l PEPTONURIA. chap. IV.] 

obscure cases of local disease, great 
probability in favour of the existence of 
an inflammation of a suppurative charac- 
ter, rather than that of any other morbid 
state. In malignant new growths of rapid 
development there may be, though rarely, 
peptonuria. In nephritis — acute and sub- 
acute, but especially in acute — peptones 
have been found (Eichwald). 

(2) In lobar pneumonia — especially in the 
period of resolution — and in pleurisy^ Pep- 
tonuria is very frequently met with. In 
pneumonia it has also been found before 
resolution occurs, or in the course of grey 
hepatization ; but less often than during 
resolution. 

In twelve cases of acute rheumatic 
effusion Jaksch found peptonuria in all. 
Peptones are apt to appear in the urine 
when exudations (purulent, &c.) are ab- 
sorbed in any part. 

(3) -^^ general diseases (infective or not) pep- 
tonuria has been detected ; such as in 
diphtheria, malarial fever, typhus, typhoid 

1 Peptonuria was detected twenty-four times out of twenty- 
six cases of croupous pneumonia, and in four out of five 
cases of pleurisy. (Jacksch, quoted by Dr. Ralfe.) 



Chap. IV.] PEPTON URIA . 93 

fever, small-pox, cerebro - spinal men- 
ingitis, scurvy, purpura haemorrhagica, 
septicaemia, tertiary S3^philis, and acute 
phosphorus poisoning. In these cases it 
is sometimes indicative of profound dis- 
turbance ; as when there exists a very 
high temperature and adynamia in scurvy, 
purpura, malaria, and typhoid : but it is 
not always expressive of the intensity of 
the ailment, as it has been found in certain 
cases of slight sub-continuous miasmatic 
fevers.^ 

(4) Disorders of the liver, — I think there 
is some probability in the view, that 
peptones, generated by the digestion of 
proteids in the stomach and duodenum, 
may, in certain cases of failure in the 
construction of glycogen, pass through 
the liver into the general circulation, and 
then — being much more diffusible than 
the albumin of the blood — they will 
readily dialize through the renal glomeruli, 
and appear in the urine. In such in- 
stances, the presence of a peptone in the 

1 See Dr. Petri's paper on peptonuria in Annali Unto, di 
Med., Aug., 1884.J 

H 



94 PEPTON URIA . [Chap. IV. 

urine will be of like clinical significance 
to that of glucose, when glycosuria in- 
dicates some hitch in the constructive 
assimilation of the products of digestion 
by the liver. But the appearance of 
peptones in the urine, indicative of a 
hepatic defect, may only be a compara- 
tively rare event ; for, there is some 
reason for the belief, that the blood and 
the tissues have the power to assimilate 
them — probably by dehydration^ con- 
verting them into other forms of pro- 
teid. If this be so, it merely reduces 
. somewhat, and does not obviate the 
liability of peptones to pass out by the 
kidneys : for the failure of the liver to 
fix these diffusible proteids may be shared 
by all the tissues. The frequency of 
peptonuria in malarial disorders — whether 
accompanied by high temperature or 
otherwise — which so frequently disturb 
liver-work, and in profound febrile action 
generally, in which the metabolism of the 

1 Peptone appears to be chemically related to albumin in 
much the same way as glucose is to starch, namely, in 
being a hydrate, or albumin plus water, as glucose is starch 
plus water. 



Chap. IV.] PEPTON URIA . 95 . 

liver and of the tissues is very active 
and greatly disordered, appears to me to 
suggest the hepatic origin of pepto- 
nuria ; and the two cases of temporary 
albuminuria and peptonuria referred to by 
Dr. Ralfe, and several observations of my 
own in the same direction, undoubtedly 
support it. I am, therefore, disposed to 
place peptonuria (temporary, or intermit- 
tent, or minimal though it be) by the side 
of minimal glycosuria and the bile-salts 
(see chap, xiii.), as affording the most 
reliable clinical evidence, provided by the 
urine, of imperfect or perverted liver-work. 
Then again, I am disposed to think that 
now and then peptones in small quantity 
appear in the urine — especial!}^ an hour 
or two after dinner or the heaviest nitroge- 
nous meal — as a result of an excessive 
flow of them to the liver : the diet being 
too rich in proteids.^ Dr. Lauder Brunton, 
in his light-giving Lettsomian lectures on 

1 There is, however, some ground for believing that, as a 
rule, an ingestion of proteids beyond the requirements of the 
system is largely got rid of by tryptic decomposition : pan- 
creatin having the power to split up peptone into lencin and 
tyrosin. Still this process of destruction may not obviate in 
all cases a too free supply of peptones to the liver. 



96 PEPTON URIA . [Chap. IV. 

* Disorders of Digestion : their consequences and 
treatment,' just delivered, touches with much 
point on the ill consequences of this fact, 
when he says : ^* many a man has been 
saved by a weak stomach, which punished 
its owner by sickness or headache when- 
ever he tried to o^er-burden it, and thus 
checked his tendency towards excess at 
the very outset. Where the stomach 
and intestines are more accommodating, 
and continue to digest all that is put into 
them, the burden of the work is shifted 
elsewhere, and either the liver fails to 
reconstruct the new material with which 
it is deluged, or the tissues are poisoned, 
and the over-worked kidneys become de- 
generated." And again: *' If these products 
of digestion be absorbed in large quantity, 
and pass too rapidly through the liver, so 
that they reach the general circulation 
without undergoing sufficient elaboration, 
they will either prove injurious to the 
organism, or be excreted as waste pro- 
ducts, or both. Indeed, we find this to 
be the case, for we frequently meet with 
affections of the respiration, circulation. 



Chap. IV.] PEPTON URIA . 97 

and nervous system, which actually seem 
to be due to a kind of poisoning by pro- 
ducts formed, either in the intestinal canal 
itself, or in the blood ; and we also meet 
with cases in which sugar, peptones, and 
albumin are excreted by the kidneys, 
instead of being applied to the repair of 

the tissues Clinical experience had 

indicated a connection between long con- 
tinued digestive disturbance and organic 
disease of the kidneys, and this was 
experimentally demonstrated by Stokvis, 
who found that hemi-albumose (see p. 88) 
injected under the skin once or twice, will 
pass out through the kidneys without 
doing them any apparent injury, but if 
the injections be frequently repeated, the 
hemi-albumose, in passing through the 
kidneys, appears to excite in them organic 
disease." 

According to my observations, the con- 
ditions that prevent precipitation of pro- 
teids in the duodenum — viz., an excess of 
the proteid, or a deficiency or excess of 
bile, or of acidity — -may induce the prema- 
ture absorption of them. (See p. 206). 



CHAPTER V. 



ALBUMINURIA : 
THE DETECTION OF ALBUMIN 
BY ACIDULATION (CITRIC ACID TEST- 
PAPER) AND HEAT. 



Different modes of applying the 
test of acidulation and lieat. — If I 

take an albuminous urine of normal acid 
reaction : boil it thoroughly : and then 
add an organic acid — citric or acetic : 
and filter: I obtain a filtrate, which, ac- 
cording to the picric acid solution, or the 
mercuric test-paper, contains a small 
quantity of albumin — for the opacity 
induced by the tests does not vanish in 
either case with heat. But if, before 
boiling, I add a citric acid test-paper, or 
a drop of acetic acid to a four inch column 



Chap, v.] THE HEAT TEST, gg 

of the urine, the filtrate, as a rule, con- 
tains the very merest trace of albumin.^ 

I, therefore, conclude that boiling before 
acidulation is a less sensitive albumin- 
test than the mercuric and the picric : and, 
furthermore, than boiling after acidula- 
ting the urine to the proper degree ^ — a 
proceeding which precipitates virtually 
the whole of the albumin. 

Boiling after acidulation. 

Preliminaries. — In applying the heat 

1 I find by experiment, that if albuminous urine is acidula- 
ted as above, is thoroughly boiled, is further acidified by two 
or three drops of acetic acid, and re-boiled, the filtrate does 
not contain a trace of albumin — so far as can be ascertained 
by any direct testing. I, therefore, regard this as the most 
sensitive mode of applying heat. Its searchingness is shown 
by the fact, that according to my observations with it during 
the past few months, it has demonstrated the presence of 
albumin in all healthy urines of specific gravity 1020 or over 
— of course a-mere trace in most, but still distinctly recogniz- 
able on shading the tube with a dark back ground. With 
normal urines of lower specific gravity (e.g., 1015 or 1016) the 
presence of albumin cannot be shown in all cases by this 
mode of applying the heat test. I daily meet with normal 
urines, which, though affording no reaction after acidulating 
(by one drop of acetic acid, or by a citric test-paper) a four 
inch column in a f inch test tube and boiling, develop a 
haze in the upper boiled portion in a few seconds, after 
adding a drop or two of the acid, or another citric test- 
paper immediately following the first boiling ; and the delicate 
reaction thus obtained, is somewhat increased by the further 
application of the lamp — the urine being kept on the simmer 
for a minute. 

2 This mode of applying the boiling test was introduced 
by Dr. Wm. Roberts, op., cit. 



lOO BOILING [Chap. V. 

test after acidifying the urine, the re- 
adlion should first be taken ; if alkahne 
or neutral, the urine should be acidified 
slightly, or up to the supposed normal 
degree, before the observer adds the 
standard quantity of acid ; but, if nor- 
mally acid, no such redlification is 
required. If the urine be per-acid — as 
indicated, for example, by the deposition 
of urates — though there are many per- 
acid urines free from such deposits — 
boiling may proceed without any pre- 
liminary acidification. But in any case 
the observer requires to be always on 
his guard, lest he should unwarily create 
a pitfall by over - stepping, even only 
slightly, the required degree of acidity : 
for, then he will prevent the coagulation 
of even a large quantity of albumin ; 
this may easily occur, if he overlooks the 
per-acid state of a urine, and in a routine 
way, adds the quantum of acid, determined 
by experience as the best, when the urine 
is normally acid prior to testing. 

Tlie Method. — The most convenient 
way of acidifying and boiling for bedside 



Chap, v.] AFTER ACIDULATION. loi 

observation is : to fill the test tube with 
the urine up to the topmost mark ; to 
add half a citric test-paper^ — after acidi- 
fying to the normal degree alkaline or 
neutral urine with small pieces of the same 
paper ; and then to boil the upper half 
of the column. Any opacity that appears 
is albumin, and nothing but albumin. 

Olijecti©ii« — According to my observa- 
tions this mode of testing is undoubtedly 
open to the objection that has been urged 
against albumin -precipitants more deli- 
cate than nitric acid : that for clinical 
purposes they go too far, and include 
within their range a very large number 
of healthy urines containing albumin in 
small quantity ; thus, either necessitating 
an enquiry into the source of the proteid 
in each case — a proceeding that must 
consume more time than can be afforded 
by most observers — or leaving the prac- 
titioner in doubt as to the clinical import- 
ance, if any, of the minimal proportions 

1 The acidity of one citric test-paper is that of one and a 
half drops of acetic acid (B.P.). Hence half a paper in 2 
drams of urine is equivalent to one drop of acetic acid in 
3 drams — the proportion advised by Dr. Wm. Roberts. Op. 
cit., p. 186. 



lO^ ALBUMIN IN [Chap. V. 

of albumin thus brought to light. Should 
the observer carefully apply the heat test 
after proper acidulation — using either 
acetic or citric acid, for both give the 
same results — to a series of urines, he 
will, I think, be somewhat astonished to 
find what a large proportion of healthy 
urines — or rather of urines of healthy 
people — contain a trace of albumin : the 
merest trace, it is true, in many — but just 
sufficient to enable anyone to decide that 
they are not chemically free from albu- 
min. I have carefully and repeatedly 
watched, by the heat test with previous 
acidulation, the temporary appearance of 
small quantities, or traces, of albumin in 
urines generally regarded as albumin-free 
— though not absolutely so — due to tran- 
sitory hygienic, dietetic, or climatic 
influences, such as a slight biliary dis- 
turbance, a little indigestion, chilling, 
meteorological impressions, cold bathing, 
&c. Surely these and many other similar 
conditions of life must affect every one, 
less or more, and thus induce the appear- 
ance in the urine of the traces of albumin 



Chap, v.] HEALTHY URINE, 103 

SO frequently met with. It may be true 
that a perfectly normal urine is, so far 
as can be ascertained by direct testing, 
absolutely albumin-free : but I am per- 
suaded, that the attribute of normality 
which this dictum implies, does not apply 
to the majority of healthy persons. 

All Albumin Test reqiiii'ed of 
Intermediate Betectiiig^ Power 
between Nitric Acid and Meat 
witli Acidiilation. — Nitric acid falls far 
short of heat as a sensitive test. If the 
observer will take an albuminous urine, 
dilute it with albumin-free urine, until 
nitric acid, when run below it after the 
' contact ' method, fails to give an im- 
mediate indication of the presence of 
albumin, but one, nevertheless, that 
develops as a delicate zone in the course 
of a minute: he w^ill find that, after 
several further dilutions with albumin-free 
urine, or with brine, acidulation and 
boiling will distinctly detect the albumin 
^and even when diluted five-fold, a haze 
will still be apparent. Hence, I conclude, 
that nitric acid is an albumin test at least 



104 NITRIC ACID AND HEAT. [Chap. v. 

five times less delicate than acidulation 
and boiling. And this position, further- 
more, agrees with clinical observation. 
Repeatedly during the past few years 
nitric acid has afforded me negative 
evidence of albumin, or has indicated 
mere traces, when heat and other tests 
have shown the pressure of definite 
quantities, the detection of which was 
a matter of some clinical importance and 
interest. It would therefore appear, that 
for clinical purposes, nitric acid is 
as insufficiently acute, as acidulation and 
boiling, and other tests of similar delicacy, 
are too sensitive ; for, in using always the 
former the observer occasionally runs the 
risk of over-looking pathological albumin, 
and in employing the latter, in the same 
routine way, he is apt to be confused by 
physiological albumin-or by the transitory 
traces of albumin determined by condi- 
tions of little or no clinical importance. 
What is, therefore, needed as most useful 
for all ordinary observation, is a reliable 
test of intermediate power, or as Dr. 
Wm. Roberts says, ''It is no doubt 



Chap. v.] ACIDIFYING AFTER HEAT. 105 

desirable that we should possess a test 
for albumin, somewhat more sensitive 
than nitric acid, but it is a condition, 
sine qua non, that such a test shall be 
equally reliable."^ 

As I will show presently, the albumin 
precipitants I use for bedside purposes, 
when employed in a definite manner, 
provide three ranges of power : that of 
nitric acid, that of acidulation and 
boiling, and that of an intermediate 
degree ; and, moreo er, the reliability of 
the tests is increased, if not ensured, by 
the improved mode of applying them. 

Acidulating after toiling. 
If the observer prefers to employ heat 
in the ordinary way, he should boil the 
upper half of the column of urine, and if 
any opalescence appears, he should insert 
into it a citric paper ; then, if the opacity 
vanishes with effervescence, it is due to 
phosphates, and any turbidity that re- 
mains arises from coagulated albumin. 

Meat not necessary as a routine 
Preliminary Test.— Boiling along with 

1 op. cit, P. 189. 



Io6 HEAT NOT NECESSARY [Chap. V. 

acidulation will always maintain its posi- 
tion as an albumin test. But I am 
satisfied it is not a necessary condition of 
safe clinical observation to always resort 
to it in order to answer the routine 
preliminary enquiry — is the urine albu- 
minous or not ? As every one knows, it 
is only here and there in the ordinary 
course of work, that albumin of clinical 
significance is met with ; and when, as in 
the great majority of the samples of urines 
tested, the handier tests give no indica- 
tions, the observer may rest satisfied that 
boiling will be equally negative, and the 
enquiry is at an end ; and in the com. 
paratively few cases in which they do 
afford indications of the presence of 
albumin, the practitioner may, if he so 
wish, verify the result by the boiling test ; 
but a little experience will soon show him 
that this appeal is but rarely necessary. 

As a rule heat is selected over other 
tests when a urine is loaded with lithates, 
because it is general^ necessary to first 
of all clear these away with warmth, and 
then it is a simple matter to carry the 



Chap. v.] AS A PRELIMINARY TEST. 107 

heating forward to boiling ; and, further- 
more, such a urine is always sufficiently 
acid for albumin testing by heat. But 
this condition does not lead me to select 
heat as the preliminary test ; for, the 
procedure I adopt does not require the 
urates either to be cleared up by heat, or 
to be filtered out. 

Then again, an opacity due to earthy 
phosphates is clarified by the acidulation 
prior to boiling : but this does not con- 
stitute a preference for heat ; for, in the 
cold mode of testing presently to be 
described, the phosphatic turbidity 
vanishes as readily as does the dense 
cloud of urates. 

If a urine is turbid from organic causes 
— pus, blood, &c., — it should be filtered ; 
but if this is impracticable, or a clear 
sample derived from subsidence cannot 
be obtained, heat is preferable as the 
preliminary test. 

Tlie modes ©f Heating.— At the bed- 
side cleanly heating and boiling are best 
effected b}^ either of the following 
ways : — 



Io8 MODES OF HEATING. [Chap. V. 

(a) A long wax match, or taper, or 
candle ; the tube being always held clear 
of the tip of the flame, when smoking of 
the glass will be entirely avoided. A 
little practice will enable the observer to 
boil by these simple means in as smokeless 
a manner as by the spirit lamp. 

(h) Neat little spirit lamps provided by 
the instrument makers. 



CHAPTER VI. 



ALBUMINURIA : 

THE DETECTION OF ALBUMIN 

BY TEST-PAPERS. 



The Test-Papers Selected. — Of the 

series of albumin-precipitant test-papers, 
which some two years ago, I brought 
under the notice of the profession, I am 
led, as the result of observation, to select 
two — they being, in my opinion, the most 
generally useful and trustworthy in the pre- 
liminary search for albumin in the urine : 
namely, the potassio-mercuric iodide, and 
the potassium ferrocyanide, which, for the 
sake of brevity, I will designate the ' mer- 
curic ' and the ' ferrocyanic ' test-papers. 
The test in each case consists of two 
papers : one charged with the reagent ; 
and the other with citric acid.^ 

1 I think it is best to apply the acid and the reagent papers 
separately : they are, however, combined by a thin layer of 
rubber in the compound mercuric test-paper, which, from its 
simplicity as a single paper, is preferred by many prac- 
titioners. 



no MUCIN. [Chap. VI. 

Mucin. — Exception having been made 
to the albumin test-papers, when employed 
in determining small quantities of albu- 
min, because they furnish a reaction with 
mucin — traces of which are said to exist 
in all urines — I will deal with this 
question at the outset. 

Citric Acid. — When a solution of an 
acid, such as citric,^ is run upon or 
under normal urine of specific gravity 
I020 or thereabouts, and kept warm, so 
as to prevent precipitation of urates, there 
appears, generally in the course of several 
minutes, along the plane of contact of the 
fluids, a delicate whitish zone, which 
gradually becomes somewhat more and 
more pronounced. This reaction is said 
to arise from the presence of a small 
quantity of mucin held in solution by all 
urines, acid as w^ell as alkaline, healthy 
as well as morbid. ^ 



1 For example, a citric test-paper, dropped into 20 minims 
of water, provides a solution sufficiently acid, when run upon 
the urine, to produce the mucin reaction. 

2 If the observer prepare an acid solution of mucin — as by 
dissolving by aid of heat the purified mucin derived from ox- 
bile in water containing a vegetable acid, as citric or acetic ; 
or by precipitating the trace of albumin present in clear 



Chap. VI.] MUCIN. Ill 

It follows that all acid reagents, em- 
ployed for the detection of albumin in 
small quantity by the contact method, are 
open to the fallacy of the mucin reaction.^ 

But this reaction, concentrated by the 
contact method, becomes inappreciable 
when diffused throughout the urine : as 
when a citric test-paper is dropped into 
60 minims of transparent urine. Then, as 
a rule, the keen observer will either fail to 
detect any alteration at all, or only one of 
the slightest :^ but, if the mucin is present 
in larger quantity than is usually met 
with, a slight milkiness will appear ; and 

diluted saliva by heat and acidulation, and after filtering, 
or even without filtering, acidifying and reboiling — he will find 
that citric or any other acid, will not precipitate the albu- 
minoid. Then, it may be asked, if ordinary acid urine con- 
tain a trace of mucin in solution, why is it precipitated by an 
acid ? The explanation appears to me to be suggested by my 
experiments with the bile-salts. See Ch. xii. 

1 Even the slight acidity of picric acid is not an exception 
to this rule: for, when the solution of this reagent is not 
allowed to mix beyond a very limited extent with normal 
urine of specific gravity 1020 or more, there develops a 
delicate zone, in the course of a few minutes, which may be 
mistaken for a trace of albumin, as was the case, I fear in all 
my earlier observations. If this delicate reaction is not due to 
albumin, what is its cause, if not mucin ? 

2 Except when urates are precipitated — a comparatively 
rare event— or when bile-saits are present in excess, along 
with albumin. (See pp. 207-9). 



112 MUCIN. [Chap. VI. 

this delicate reaction will put the observer 
on his guard. 

The Mercuric Test-Paper, — On, however, 
using the mercuric test-paper after the 
acidification, a very delicate haze, if it 
can be said to amount to such, may be 
detected, on holding up the urine under 
examination to the light, by the side of a 
tube containing the native urine, shaded 
by the hand or by some dark back-ground. 
This very diminutive reacftion appears in 
all healthy urines, and is so slight and 
usual, that the observer, in the ordinary 
course of testing, will either not recognize 
it at all, or, if he does, he will disregard 
it, or estimate it as a 'constant quantity,' 
and, therefore, of no clinical significance. 
When, however, mucin is present beyond 
the normal proportion, the milkiness be- 
comes recognizable, and suggestive of a 
trace of albumin. 

If the observer take a urine, which, 
according to the ordinary use of heat and 
acidulation is free from albumin ; filter it, 
to ensure perfect transparency ; pour 60 
minims of it into two test tubes of the 



Chap, vi.i MUCIN. 113 

same diameter, one for the testing, and the 
other for checking results ; note the sHght 
haze induced by the citric and mercuric 
test-papers, as compared with the trans- 
parency of the native urine ; and apply 
heat : he will find, on nearing the boiling 
point, the urine under examination will 
become as clear as the untested speci- 
men; but, on cooling, he will observe an 
opacity, which far exceeds the original 
haze, and which, on re-heating, vanishes, 
either entirely, or almost entirely. Such 
is the mucin reaction with the mercuric 
test-paper ^ 

1 The reactions of mucin may be readily studied experi- 
mentally by impregnating normal urine with saliva — a 
secretion which contains a large quantity of mucin. The 
clear saliva and a solution of salt (say 20 grains to the ounce) 
should be mixed together in equal parts ; and one drop of 
acetic acid, or a citric paper, should be added to a 4 inch 
column, which should then be thoroughly boiled, when the 
milkiness produced by a trace of albumin will appear. This 
highly muciparous solution is now added to albumin-free 
urine — in such proportion as the observer may wish to charge 
it with mucin, e.g., i to i or i to 2. In any case the urine will 
then become more highly muciparous than is likely to be met 
with in the course of practice. Filtration may be dispensed 
with — being slow — if observation be checked by some of the 
untreated fluid, held by the side of that experimented 
on. A citric and a mercuric test-paper added to 60 minims, 
produces an opacity, exactly like that induced by a small 
quantity of albumin ; but it differs from it incompletely vanish- 
ing when heated. The opacity returns as the temperature 



i 14 MUCIN. [Chap. VI. 

If now, however, the observer employs 
the test solutions, he will, in all probability, 
obtain results which differ from those 
produced by the test-papers, the re- 
action being much more pronounced, and, 
moreover, not clearing at all with heat. 
Experiment has shown me, that the 
cause of this disparity is to be found in 
the varying quantities of the reagents 
added to the volume of urine submitted 
to examination ; that when they exceed a 
certain proportion, — that uniformly sup- 
plied by the test-papers to 6oirt of urine, — 
heat can no longer clear up the haziness, 
the excess of the mercuric salt preventing 
solution. I, therefore, regard the test- 

of the solution falls, and in the cold it greatly exceeds the 
original amount. Heat will again disperse it as before. 
The characteristic feature of the reaction is the great in- 
crease of the opacity which follows the clearing up by heat; 
just, in fact, what occurs with normal urine, and also with 
urine which contains an excess of mucin. No doubt the 
observer, taking into account the highly muciparous character 
of the urine, will be surprised by the slightness of the 
reaction, after dropping in the test-papers ; and he will, 
moreover, find that lo minims of it, when added to the 60 
minim solution prepared from the test-papers (see p. 122), 
gives the faintest tinge of milkiness, which heat, far short of 
boiling, completely removes. If now a trace of albumin be 
communicated to the mucin-charged urine — as by adding 
a little albuminous urine — the test-papers will produce an 
opacity, which heat will clear up only to a certain degree ; 
that which remains over being due to the albumin. 



Chap. VI.] MUCIN. 115 

papers as possessing a distin(5l clinical 
advantage over the solutions. 

If the observer charge the normal 
urine with a trace of albumin, by adding 
a few drops of an albuminous urine, he 
will, on using the test-papers, fail to 
disperse the slight opacity by heat, even 
when applied to the boiling point. I 
therefore conclude, that in employing the 
mercuric test-paper, mucin must be classed 
with urates and all other possible fallacies 
which are dispersed by heat, and are thus 
proved to be non-albuminous. And this 
position, is, moreover, confirmed by all 
my observations on the working of these 
test-papers during the past two years ; 
for I have invariably found, that an 
opacity produced by them, that would 
not vanish with heat, was albumm, and 
nothing but albumin — a fact proved by the 
heat test, to which I have been in the 
habit of appealing for verification. 

My clinical experience of this test- 
paper also leads me to estimate an 
objection to it on the score of mucin, as 
of but little practical importance ; for, in 



Il6 MERCURIC TEST-PAPER. [Chap. VI. 

any case, it can only apply to such small 
quantities of albumin as are clinically 
quite insignificant, and then heat comes in 
as a corrective. 

But, with the view of obviating the 
rather frequent resort to heat, which, in 
careful testing, the test-paper used in the 
manner hitherto followed — i,e., dropped 
into the urine — is apt to provoke, I have 
for some time followed a method, which 
not only affords a negative result in all 
normal urines, but reduces to an infinitesi- 
mal degree the liabilit}^ to error from 
mucin and other causes (see p. 122.) 

The Fevvocyanic Test - Paper reacts but 
little with the urinary mucin, and it 
certainly has not once led me to suspect 
the presence of albumin, which could not 
be readily demonstrated b}^ other tests. 

The Mercuric Test-Paper. 

Potassio-mercuric iodide was brought 
forward as an albumin precipitant by M. 
Chas. Tanret, of Paris. ^ According to 

1 See Journal de Connaissances Mcdicales, Mai 15, 1872 ; 
also " Recherche et dosage de Valhumine dans Vurifie" Bulletin 
de Thivapeutique, 15 aout 1877, p. 308. 



Chap.VL] MERCURIC TEST-PAPER. ny 

my observations it is the most sentitive 
test known. The precipitate it produces, 
being dense, bulky, and white, enables the 
smallest quantities of albumin to become 
more apparent than when thrown down 
by other reagents. The keenness of 
the test is indeed so great in attacking 
every vestige of proteid in the urine, that 
on this very account objections have been 
raised to it : for it has been alleged, that it 
induces a reaction in the majority of nor- 
mal urines, and brings within view traces 
of albumin of no clinical significance. 

In order to meet this objection I no 
longer advise the test-paper to be dropped 
into the urine : but to be so used as to 
furnish three ranges of albumin-detecting 
power ; namely, one on a par with that of 
nitric acid, one with that of heat, and an- 
other of intermediate degree. (Seep. 123-4). 

Bodies Precipitated. — Used in this 
way, the only substances thrown out of 
solution by the test-paper are : — 

(i) Alhtmin. 

(a) Native pvoteids, — Serum-albumin, 
and globulin. 



1 18 ALKALOIDS. chap. VI.] 

(b) Albuminates, — Acid and alkaline 
albumin. 

(2) Peptoid bodies, 

(a) Peptone, 

(b) Hemi-albumose, 

(3) Alkaloids. 

When a precipitate appears, the solution 
should be boiled. If the opacity remains 
without change, or is intensified rather 
than otherwise, it is caused b}^ a form of 
albumin: if, however, it clears up, either 
partially or entirely, a peptoid body, or an 
alkaloid (see below) is present along with 
albumin or without it ; and in this case, as 
the solution cools the opacity returns and 
acquires its original intensity. 

Alkaloids. — When a patient is taking 
vegetable alkaloids, such as quinine, 
morphia, &c., the mercuric test --paper 
precipitates them like albumin. But 
if the observer suspects the presence 
of an alkaloid in the urine, he will deter- 
mine the matter before testing for 
albumin, by dropping the reagent paper 
only into the urine, when an opacity will 
appear if an alkaloid is being eliminated by 



Chap. VI.] FERROCYANIC TEST-PAPER. 119 

the urine ; otherwise the transparency^ of 
the urine will remain unimpaired, and the 
citric test-paper may be added to deter- 
mine the precipitation of any proteid 
present. Should the observer detect an 
alkaloid, he may either select the ferro- 
cyanic test-paper (which does not precipi- 
tate alkaloids), or test for albumin, by 
dropping the mercuric and the acid test- 
papers into the urine contained in another 
test tube, and compare the two opacities. 
Inasmuch as the mercuric precipitate of 
alkaloids is soluble with heat, any opacity 
remaining over after boiling the urine, 
rendered turbid by using the acid along 
with the reagent paper, is albumin. 

The Ferrocyanic Test-Paper. 
When employed after the methods to 

1 It is somewhat curious that the mercuric chloride should 
cause a precipitate in non-acidulated urines, while another 
mercuric salt — the potassio-mercuric iodide — does not. Some 
years ago, Dr. John Greene, of Birmingham, used the mer- 
curic chloride (without acidulation) for the purpose of 
precipitating a body, denominated by him 'leth-albumin,' 
which is found in all urines in varying quantities. (See 
Brit. Med. Jour., vol. ii., 1879). In a notice of the second 
edition of this little work, which appeared in the Birmingham 
Medical Review, the potassio-mercuric iodide as a test for 
albumin was actually called in question because of the re- 
action of mercuric chloride with ' leth-albumin ' 1 



I20 PERROCYANIC TEST-PAPER. [Chap. Vi. 

be described, this test-paper forms a 
very reliable work-a-day test for albumin. 

Bodieis precipitated.— The behaviour 
of the ferrocyanic test-paper on the pro- 
teids of the urine differs from that of the 
mercuric ; for, while this precipitates every 
member of the group without exception, 
the ferrocyanic exempts the peptones.^ 
In this respect it must be classed with 
nitric acid, which detects every form of 
proteid except peptones. 

In discovering very small quantities of 
albumin — such as those beyond the range 
of nitric acid — the ferrocyanic is some- 
what less sharp than the mercuric test- 
paper ; for, while the latter reacts 
instantly, the former does so gradually in 
the course of the minute to be devoted to 
the observation. But, when albumin is 



1 The reader will bear in mind, that experiment shows that 
the ferrocyanic test-paper freely precipitates peptones in 
mere aqueous solution, but fails to do so when jt is dissolved 
in salt water or in urine. Kiihne has recently shown (Zeit. filr 
Biol. Brand, xix.; that potassium ferrocyanide does not preci- 
pitate hemi-albumose, when there is an excess of sodium 
chloride, or of the reagent : inasmuch, therefore, as the test- 
paper, or the urine does not provide that excess, the ferro- 
cyanic test does not exempt hemi - albumose as well as 
peptone from precipitation. 



Chap. VI.] MODES OF TESTING. 121 

present beyond traces, the ferrocyanic 
precipitation is as decisive as the mer- 
curic. 

In using the ferrocyanic test-paper the 
observer does not require to be on his 
guard against a quasi-albuminous pre- 
cipitate from alkaloids present in the 
urine. In fact, when this test-paper is 
employed after the improved method 
which provides three ranges of albumin- 
detecting power, there are no fallacies to 
be encountered. Heat is, therefore, not 
required as a corrective ; and this is 
fortunate, for, though warmth sufficient 
to dissipate urates — as when the test- 
paper is merely dropped into the urine — 
does not of itself induce an opacity from 
decomposing the test, boiling does. 

The Modes of Testing. 

The specimen of urine submitted to 
examination should, if possible, be clear 
(see p. 18), and this precaution is essential 
if it contain organic elements — pus, blood, 
&c. 

The observer may follow one or other 



122 MODES OF TESTING. [Chap. VI. 

of the following modes of testing : and of 

the two, I give decided preference to the 

first. 

Method L 

A reagent (mercuric or ferrocyanic) 

and a citric test-paper are dropped into 

the test tube : and water^ is added to the 

6oTrt lii^^- 

After gentle agitation for half a minute 
or so, the test-papers are removed, and 
the transparent solution is ready for the 
testing. 

The pipette, containing the suspected 
urine, is held in a vertical position over 
the tube, and the urine is delivered in 
drops : the number of drops to be added 
varying with the reagent selected and 
the range of albumin-detecting power 
preferred. 2 

1 It is immaterial whether the water be soft or hard : it is 
only essemial it should be clear. 

2 This matter I carefully determined by experiment. An 
albuminous urine was diluted by normal urine, until it failed 
to afford an immediate reaction with nitric acid run down 
below it : but provided a very delicate zone in the course of 
a minute. The urine was then regarded as containing a trace 
of albumin according to nitric acid. How much of it was 
required to produce a slight but detectable reaction in one 
minute by the mercuric and ferrocyanic test solutions pre- 
pared from the test-papers? Experiment showed that 4 drops 
were needed by the former, and 6 drops by the latter, 



Chap" VI.] MODES OF TESTING. 123 

The Nitric Acid Rang^e. — If 4 drops 
of the urine, added to the mercuric 
solution prepared from the test-papers 
or 6 drops to the ferrocyanic^ solu- 
tion, do not produce a trace of milki- 
ness, when the contents of the tube are 
viewed against a dark back ground, the 
observer may safely infer, that if albumin 
is present, it is in so small a quantity, that 
nitric acid, applied after the ' contact ' 
method for one minute, will not discover 
it. If a slight milkiness is apparent, it 
will represent a trace of albumin detect- 
able by nitric acid. The degree of opacity 
produced, will of course be increased on 
dropping in the urine up to the next 
range of albumin-detecting power : and 
any doubt as to a reaction on the verge 
of the nitric acid range will thus be re- 
solved. 

before a delicate milkiness was apparent when the test tube 
was held before a dark back-ground. Then it was found, 
that when the urine was diluted by a solution of salt five- 
fold, heat with acidulation detected a trace of albumin. How 
much of this further attenuated albuminous urine was needed 
to produce a slight reaction with the test solutions? 20 drops 
in the case of the mercuric, and 30 in that of the ferrocyanide, 
1 The observer should give the ferrocyanic solution a 
minute, in which to develop a reaction from a trace of 
albumin. 



124 MODES OF TESTING. Chap. VI.] 

The Intermediate Range. — J pro- 
pose this for the purpose of detecting a 
trace of albumin, which cannot be de- 
monstrated by nitric acid in one minute, 
but can be readily shown to be present by 
heat and acidulation. For the mercuric 
test lo drops, and for the ferrocyanic 15 
drops are required. 

Tlie Heat Rang-e. — When albumin is 
present in such small quantity as to be 
indicated by heat after proper acidulation 
as a fine haze, experiment has shown, that 
a corresponding reaction is produced in 
the mercuric and ferrocyanic solutions, 
when the urine is added in the proportion 
of 20 drops to the former, and 30 drops 
to the latter. 

These several ranges, therefore, require 
the following quantities of urine to be 
dropped into the test solutions : — 

Mercuric sol. Ferrocyayiic sol. 

Nitric A cid 4 drops or 2m . . 6 drops or 3m 
Intermediate 10 ,, 5m ..15 ,, 7m 

Heat 20 „ 10m ..30 „ 15m 

Heat nmist supplement the Mer- 
cnric Test if a reaction appears. — 
In the case of the mercuric test, if a 



Chap. VI.] MODES OF TESTING. 125 

reaction occurs, the solution should be 
boiled, so as to prove the presence or 
absence of one of the diffusible proteids — 
peptone, or hemi-albumose. If the opacity 
is unaffected by heat, or is intensified by 
it rather than otherwise, it is albuminous ; 
but if it is diminished, or is entirely 
removed thereby, presumptive evidence 
is afforded of the presence of a peptoid 
body, either along with albumin, or alone. ^ 
The mercuric test supplemented by heat, 
therefore, provides the observer with a 
fuller knowledge of the proteids which 
may appear in the urine than the ferro- 
cyanic, which precipitates albumin onty. 
Urines tiirl>id from Urates and 
Pliospliates.— Though, of course, it is 
always desirable to take a clear sample 
of urine, I find, in following this mode of 
testing, the mere presence of lithates and 
phosphates does not impair the delicacy 
of observation ; for, the turbidity of the 
drops clears up as they mix with the 
solution, and the transparency is not 
impaired by them if the urine is albumin- 

1 According to my observation, this mode of testing pre- 
sents no other reason than this for the corrective use of heat. 



126 MODES OF TESTING. [Chap. VI. 

free. Moreover, all other modes of 
albumin-testing in the cold are liable to 
confusion from the precipitation of urates 
— a fallacy to which this is not open. 

Reaction ^itli mucin not ap- 
parent. — So far, I have not been led 
to an inaccurate conclusion from the 
mucin reaction : and it must be apparent, 
from the small quantit}^ of urine required 
— especially when the testing proceeds on 
the nitric acid, or even the intermediate 
range — that the liability to this source 
of error must be quite insignificant. 

Quantitative Albumin. — This mode 
of using the test-papers is but the first 
stage of the method which I follow for 
approximately determining at the bedside 
the quantity of albumin : so that, if a 
readlion appears with the small quantities 
of urine required merely for the quali- 
tative testing, the observer may proceed 
at once to the quantitative estimation 
described in the next chapter. 

Method 11. 
If the density of the urine exceeds 



[Chap. VI. MODES OF TESTING. 127 

loio, it should be diluted with an 
equal part of water : or the sample of 
urine, in which the specific gravity has 
been determined, should be used without 
further dilution. 

Sixty minims of it are transferred to 
the test tube. 

It is rendered strongly acid by dropping 
into it a citric paper, ^ which may be 
allowed to remain, or may be withdrawn, 
after the interval of a few seconds. 

The reagent paper^ is then let fall into 
it, and the observer awaits the result, and 
should not shake the tube with a view to 
hasten the reaction. 

If albumin is present in small quantity 
— e.g., a tenth of a per cent, or less 
— a whitish cloud will o^ather about the 



1 If the urine has a distinctly ammoniacal odour, it may, 
perhaps, be safer to use two citric papers. 

2 If the presence of an alkaloid be suspected, the observer 
should first of all use the mercuric test-paper, and afterwards 
acidify with the citric ; for then a milkiness that appears 
prior to the acidification, will be caused by an alkaloid, and an 
opacity, or an increased opacity that follows it, will arise 
from the proteid present. I prefer, as a rule, to acidify in the 
first instance, because many urines — those containing earthy 
phosphates in suspension — are clarified thereby, and any 
reaction that follows is thus rendered more definite. 



128 MODES OF TESTING, [Chap. VI. 

paper, and will collect in the lower 
half of the column of urine : if there 
be only a trace, the opacity will of course 
be slight, and will be more readily detected 
by intercepting the light b}^ a dark back- 
ground, such as the coat sleeve, &c. ; 
while, in striking contrast, the upper part 
of the urine will remain clear. If, how- 
ever, the albumin is met with in larger 
proportions, it does not usually produce a 
haze, but coagulates about the paper, and 
drops down in clots : the observer wall 
then note the gathering of the precipi- 
tate in the lower portion of the urine into 
a cloud, the density of which varies 
according to the amount of albumin, 
while the urine above retains its trans- 
parency. The contents of the tube may 
now be shaken up, when the whole of the 
urine under examination becomes less 
or more opaque, in proportion to the 
quantity of albumin present. In the case 
of the mercuric test, heat should be 
applied, and any turbidity that remains 
after boiling is albumin. 

If, on the other hand, after dropping in 



Chap. VI.] MODES OF TESTING. j^g 

the reagent paper, the urine preserves its 
brightness, or any sHght turbidit}^ it pos- 
sessed prior to testing is not increased, 
the observer may safely infer it is free 
from albumin.^ 

The Metliods originally proposed. 
— In the former editions of this work I 
directed the test-papers to be dropped 
into the urine without dilution. But I no 
longer advise this mode of observation : 
because experience has shown that it is 
open to certain fallacies, which are apt to 
mislead the observer ; such, for example, 
as the not infrequent precipitation of 
urates in concentrated urines — a precipi- 
tation which often wonderfully resembles 
the albuminous one — and the mucin reac- 
tion. It is true that heat is a corrective 
— at any rate with the mercuric test- 
paper — but, having to resort to it fre- 
quently, and here and there merely to 
disprove the presence of albumin, is 
somewhat troublesome. Then again, 
cases have been met with in which, 

1 In using the compound mercuric test-paper, the observer 
merely requires to drop one into the diluted urine. The reac- 
tion, however, does not appear quite so quickly as when the 
acid and the reagent test-papers are applied separately. 



130 MODES OF TESTING. [Chap. VI. 

though the urines were very highly 
charged with albumin, no precipitate fell 
when the reagent paper was dropped in ; 
because, the instant it came into contact 
with the heavy load of albumin, the pre- 
cipitant became locked up by a dense 
film of coagulum, which formed all over 
the paper. 

Hence, experience has drifted me to 
one or other of the modes of testing just 
described : the first obviating entirely the 
fallacies to which the original method was 
liable ; and the second minimizing them. 

I also suggested the ' contact ' method 
as an effective wa}^ of using these test- 
papers — a solution, prepared from the 
reagent paper, being run upon the 
acidified urine : a zone of precipitation 
appearing along the plane of contact of 
the fluids, when albumin is present. But 
as already indicated (see p. no), this 
method of albumin testing is liable to the 
fallacy of the mucin reaction ; and a zone 
of amorphous urates, which w411 simulate 
albumin, may also form and mislead the 
observer. 



CHAPTER VII. 



ALBUMINURIA: 
QUANTITATIVE ALBUMIN. 



The Mettiods. — The test-paper mode 
of urine-testing admits of two methods, 
by which the quantity of albumin may be 
determined on the spot, as an addendum 
to the quaHtative observation : namely, 
one which provides at once the amount 
of albumin as a fraction of the column 
of urine — ^just as the mode of deposition 
after boiling and acidulation furnishes in 
twenty-four hours the same information ; 
and the other expresses the quantity as 
so much per cent. The former method 
has the advantages of putting the quanti- 
tative information in the form familiar to 
all practitioners, and of being sufficiently 
approximate in the preliminary enquiry 
at the bedside : while the latter affords 



132 QUANTITY OF ALBUMIN [Chap. VIl. 

more precise results, and is perhaps better 
adapted to observation at home. 

Method L 

The Quantity of Albumin Expressed 
AS A FractioNx\l Part of the Column 
OF Urine. 

The method of deposition, as ordinarily 
performed after boiling and acidulation, 
furnishes precipitates which in bulk are 
not strictly proportionate to the amount 
of albumin — the smaller quantities of 
albumin, though of course appearing less 
bulky than the larger, providing relatively 
less compact and apparently greater 
deposits. And besides this source of 
irregularity, there is another frequently 
overlooked : and that is the time during 
which the albumin is allowed to settle ; 
for unless it be uniform, not only with 
one practitioner, but with all, the data 
thus obtained are not comparable — or 
they can only be collated in the sense 
that it is justifiable to reckon fives as 
nines, or sevens as fours, and the like. 



Chap. VII.] EXPRESSED AS A DEPOSIT. 133 

The Mode of Testing-.— The quan- 
titative method, which translates at once 
the amount of albumin as so much bulk 
of coagulated deposit, is founded on the 
data provided by the subsidence of 
twenty-four hours. 

The practitioner having determined the 
presence of albumin by the first described 
qualitative mode of procedure (see p. 126) 
will ascertain an approximate notion of 
the amount by observing the following 
directions. 

He places immediately behind the tube 
the card on which fine lines are printed 
(see ch. xiv.) : and selects a good re- 
flected light. 

So long as the lines are distinctly 
visible, he adds the albuminous urine 
according to the stages marked on the 
tube (see ch. xiv.) — shaking the contents 
after each addition : and when, from the 
increased opacity, they pass out of view, 
the amount of albumin, as so much deposit 
in twenty-four hours, is read off. In this 
way the observer obtains a ready gauge 
of ten different proportions of albumin. 



134 -^^^ PERCENTAGE [Chap. Vli. 

If, after adding a certain quantity of 
the urine, the Hnes become more visible 
than before, it is useless to proceed fur- 
ther : for the urine in that case contains 
less albumin than is represented by ^ 
deposit. 

When the lines are occluded by the 
mere addition of urine to the lowest mark 
on the scale, the urine contains so much 
albumin as to solidify on boiling. 

Method IL 

The Percentage Estimation of 
Albumin. 

The apparatus required are : — 

[a) A permanent standard of opacity 
representing -^^ per cent, of albumin 
precipitated by the mercuric or the 
ferrocyanic test-paper. (See ch. 
xiv). 

{b) A flattened tube of definite diame- 
ters, and graduated. (Seech, xiv). 

{c) Printed lines. (See ch. xiv). 

The Mode of Testing-. — If the quali- 
tative observation has shown the presence 
of albumin in pretty considerable quan- 



Chap. VII.] OF ALBUMIN. 1 35 

tity, a measured portion of the urine 
should be diluted to twice, or three, or 
four times its bulk : and the results of the 
quantitative testing must then of course 
be multiplied by the number of dilutions. 
But if the urine has been found to be only 
moderately albuminous, it is not advisable 
to dilute it. 

Fifty minims of the urine — or of the 
diluted urine — are poured into the flat- 
tened tube : the observer being careful to 
make the lowest part of the meniscus on 
a level with the graduation line. 

A reagent paper (mercuric or ferro- 
cyanic) along with the citric paper is 
dropped in, and the contents of the tube 
are shaken, or are made to oscillate up 
and down the tube while the thumb is 
held over the mouth for about a minute, 
when all the albumin will be precipitated. 

The card bearing the printed lines is 
placed close behind the tube and the 
standard of opacity, and if the opalescence 
of the precipitated albumin is seen to 
exceed that of the standard, water must 
be added until the two are exactly 



136 THE PERCENTAGE [Chap. VII. 

equalized ; and dilution may proceed 
pretty freely if the lines are completely 
obscured, but with some care, — not more 
than lonx at a time, — when it is obvious 
the opacity only somewhat exceeds 
that of the standard, or the limit thus 
provided is being approached. The ob- 
server may remove the test-papers shortly 
after he begins to dilute the urine, other- 
wise they may obstruct observation. 

After each addition of the water, 
uniformity of the opacity is secured, by 
placing the thumb over the mouth of the 
tube, and gently mixing up the contents ; 
then is the time to view the printed 
lines, before the uniform opalesence 
after agitation gradually breaks up into 
flocculi. — as it does in a minute or so. 

In making an observation it is advisable 
to distinctly overstep the limit furnished 
by the standard opacity, and then to 
subtract lonx for this excess. 

If on diluting to 200 11X (the limit of the 
scale provided by the test tube) the 
opalescence still over-blurrs the printed 
lines, I0011X should be removed, and 



Chap. VII.] OF ALBUMIN. 137 

dilution should proceed until the opacity 
is reduced to that of the standard. In 
this case, in calculating the amount of 
albumin, the dilutions acquire a double 
value to that which obtains on the first 
filling of the tube. 

The percentage of alhimin is calculated b}^ 
multiplying -i — the determined value of 
the standard opacity — by the number of 
times the volume (5orrt) of the urine has 
been increased by dilution ; e.g., when it 
is needful to dilute the 5oiix of urine 
to 200TIX the amount of albumin is -4 
(•1X4 = '4). Inasmuch as the proceeding 
generally finishes off somewhere between 
equal volumes of the 5011X of the urine 
submitted to examination, it is desirable 
to know — in order to simplify calculation 
— what is the value of every lorrt of the 
column reached by dilution : it is -02 per 
cent. ; so that, for example, if it is 
necessary to dilute the urine to 13011^, the 
observer merely requires to multiply -02 
by 13, in order to express the per cent age 
amount of albumin (•02X i3 = *26 j^.^.) I 
will now take an example, in which it is 



138 THE PERCENTAGE [Chap. VII. 

advisable — because of the large quantity 
of albumin present — to dilute the urine 
twice before the estimation is attempted ; 
and, on determining the amount of albu- 
min present in the diluted urine, it is 
needful to carry forward the additions of 
water into the second filling of the 
graduations — the reading being indicated 
at i6oiix. In this case, the first filling 
of the tube to the 2oorrt represents 
•4 (-02 X 20=: -4), and the further dilution of 
6om, after the clearing out of loonx, gives 
in addition -24 (-02 x 6 = -12 X 2 = -24) ; 
therefore, together -64 (-4-1- -24) : but, 
inasmuch as the urine was increased from 
one volume to three by water before it 
was submitted to the estimation, the 
product must be multiplied by 3, in order 
to express the percentage amount of 
albumin (-64 X 3 = i '92 per cent.) 

When the opacity is below that of the 
standard, there is, of course, less than -^ 
per cent, of albumin present. In this case 
the quantity ma}^ still be estimated : for, 
on viewing the printed lines through the 
long diameter of the tube, the blurring 



Chap. VIL] OF ALBUMIN. 135 

equivalent to that of the standard, re- 
presents 2^ (or -05) per cent. When used 
in this way, the observer may determine 
either the presence of this small per- 
centage of albumin ; or a proportion still 
less ; or one that stands between -05 and 
• I per cent. 

Tlie Quantitative Value of eacli 
Test- Paper, — On submitting 5ora of 
urine to examination, the quantitative 
range of each mercuric test-paper is i 
per cent. : and that of the ferrocyanic 2 
per cent. Inasmuch as these really large 
proportions of albumin are only met with 
quite exceptionally, one test-paper will, 
therefore, cover all the ordinary amounts : 
and certainly the heavier quantities in all 
instances, if the observer in such cases 
dilutes the urines before estimating them. 

The Quantity of Albumin met ^litlio 
— As a rule albuminous urines contain 
less than i p.c. ; only now and then the 
amount rises to 2 p.c. ; and it is but a 
rare observation to find more than from 
2^ to 3 or ^ p.c. The proportion in blood- 
serum is only about SP-^- '• ^^^ when the 



140 ALBUMIN : PER CENT, [Chap. VII. 

urine contains this large amount, boiling 
completel}^ solidifies it. The general im- 
pression as to albumin appearing in the 
urine in larger quantities than these is 
groundless. 

Tlie l>aily Amount of Albiimiii dis- 
ctiarg^ed. — x\s with other quantitative 
estimations of urinary constituents, so 
with this, it is the determination of the 
per cent, in a portion of the urine of the 
whole day, and the total amount thrown 
out during twent3^-four hours, that is 
clinicall}^ of most importance. When the 
urine examined is part of the daily yield, 
and the latter has been measured, it is 
not difficult to arrive at the total daily 
loss of albumin in intelligible figures : for, 
it is only necessary to multiply the per 
cent, b}^ 4-p to arrive roughly at the number 
of grains to the fluid ounce ; e.g., albumin 
•6 p.c, the 24 hours' urine 40 oz., 
(•6 X 4^- X 40) z= 108 grains daily dis- 
charge of albumin. 



1 The correct figure is 4*36. 



CHAPTER VIII. 



ALBUMINURIA : 

THE CLINICAL SIGNIFICANCE OF 

ALBUMIN. 



A mere sketcli poistsiMe. — In the 

limited space at my disposal I can but 
provide a few memoranda of this large 
and important subject : which may per- 
haps enable the reader to revive his 
clinical experience. 

The conditions of each case to 
lie \^'eig-lied. — Wherever albumin is 
detected in the urine, the clinical sig- 
nificance of it must be viewed from the 
individual standpoint : and the conditions 
that determine it require, of course, to be 
duly weighed before it can be estimated. 
It is but a ' symptom ' which may indicate 
a condition of little clinical moment, or 
may signify serious organic disease. In 
all cases the important question— ^5 it due 

L 



142 TEMPORARY ALBUMINURIA, [Ch. VIII. 

to venal disease ov not ? — will present itself 
to the observer for solution. 

I. The Albuminuria is intermittent. 

Tlie fact of iiitermissioift is of clini- 
cal si§iiificaiice.— It is of importance to 
determine whether or not the albumin 
now and then disappears from the urine. 
I do not, of course, refer to the remission 
of the amount, frequently observed in the 
urine voided by albuminuric patients in 
the night or before breakfast ; but to the 
total clearing away of the albumin for 
var^ang intervals. When the albu- 
minuria is distinctly intermittent, it is 
probabl}^ not due to chronic disease of 
the kidneys ; -it is true that albumin in 
Bright's disease will sometimes diminish 
almost to the verge of disappearing — 
but it rarely vanishes entirely, unless the 
renal disease recovers.^ 

Fomctional Albuminiiria. — Tem- 
porar}^ albuminuria may appear in appa- 
rentl}^ healthy subjects. The cause is 

1 In cirrhosis of the kidney it is said, however, that albumin 
is often absent for days ; and especially in the early part 
of the disease. 



Ch. Vlll.j TEMPORA RY ALB UMIN URIA . 1 43 

often slight and obscure, such as dys- 
pepsia and bihousness ;^ or a diet unsuit- 
able, or too rich inproteids ;^ or excessive 
muscular exertion ; or prolonged exposure 
to cold bathing, or other cause of chilling. 
The alhtimimiria of adolescents is the best 
example of this class of cases : in this 
condition there is often loss of tone, 
anaemia, or digestive disorder, but not 
uncommonly the health is good ; and the 
morning's urine before breakfast is gene- 
rally normal, while that passed after 
meals and exercise contains albumin — 
the urine throughout retaining the normal 
density and colour. 

Perhaps the most marked examples of 
copious temporar}^ albuminuria are wit- 
nessed in hronchocele and exophthalmos, as 
first pointed out by the late Dr. Warbur- 
ton Begbie,3 who delineated the following 

1 On p. 206 I point out that different degrees of acidity of the 
chyme &c., may lead to temporary albuminuria and peptonuria, 
and in ch. xiii. that the discharge of an excess of bile-salt 
in the urine leads to albuminuria. 

2 There is the well-known instance of the elimination of 
egg-albumin by the kidneys of certain persons. 

3 The works of the late J. Warburton Begbie, M.D., &c., 
edited by Dyce Duckworth, M.D., &c. The New Sydenham 
Society. 



144 T^E^^PORARY ALBUMINURIA. [Ch. VIII. 

urinary features of the ailment : the urine 
normal in colour, density, and in other 
respects ; but containing albumin in con- 
siderable or large amount after meals (the 
quantity being much greater after breakfast 
than after luncheon, dinner, or evening 
meal) but absent during the hours of 
fasting — as before meals and after sleep. 
But in all forms of intermittent albumin- 
uria the urine is more albuminous after 
breakfast than after the other meals, ^ 

Temporary albuminuria may also be 
induced by: — 

(i) Medicinal irritants, such as canthar- 
ides, turpentine, carbolic acid, &c. 

(2) Alcoholic excess, 

(3) Menstrnation. "In a good many wo- 
men, for a few days before and for a few- 
days after menstruation, the urine free from 
blood-discs, leucoc3^tes, or pus, contains, 
sometimes continuously, sometimes inter- 
mittently, small quantities of albumen."^ 

1 When albuminuria is persistent the urine contains a 
larger proportion of albumin after breakfast than at other 
times : and the percentage, as well as the absolute amount, 
is least during the night. 

^Albuminuria by Sir Andrew Clark, Bart., M.D., Brit. 
Med. Journal, 1884, vol. ii., p. 312. 



Ch. VIII.] TEMPORARY ALBUMINURIA . 145 

(4) Febrile movement — zymotic or inflam- 
matory (see p. 154). 

(5) HcBmoglohinuria. 

(6) Neurotic disturbances (see p. 155). 
" Among twenty men entering a competi- 
tive examination, lasting a week, three 
are found to have albumen in the urine. "^ 

(7) Strangulated hernia. Of 74 cases, 
observed by Dr. Englisch, 39 had albumin 
in the urine, which either appeared simul- 
taneously with the strangulation, or 
several days later ; and vanished in from 
24 hours to 4 days after taxis, or success- 
ful herniotomy. According to Dr. Eng- 
lisch's observations, albuminuria — when 
not pre-existent — indicates involvement of 
the intestine in the strangulation : for 
when absent, only omentum or an appen- 
dix epiploica was found in the hernial sac.^ 

(8) Heart disease, &c. (See p. 153). 

(9) Bile-salts eliminated by the kidneys. 

(10) Acute nephritis. (See p. 152). 
When the observer suspecl:s temporary 

albuminuria he should examine specimens 

1 Sir Andrew Clark, op. cit. 

3 See Brit, Med. Journal, 1884, vol. ii., p. 672, 



146 PERSISTENT ALBUMINURIA . j-ch. VIII. 

of the urine voided two hours after a meal 
(such as breakfast) and after exercise. In 
all cases the density keeps up, and the 
colour does not diminish. 

II. The alhmiimiria is persistent. 

Tlie cause is Urinary. — When the 
albuminuria is permanent, the cause is 
nearly always referrible to the urinary 
organs — and to the kidneys in particular. 

If the amount be small — e.g. a mere 
trace — and the urine is haz}'^ w^hen voided, 
it may be merely pus-derived : as when 
there exists an inflammatory condition of 
some part of the urinary tract, or a puru- 
lent discharge ; the urine of women, and 
that of elderly men is very frequently 
of this character. 

The cause is Renal. — The per- 
manent presence of a large quantity of 
albumin is almost invariably due to 
chronic renal diseased and, as a rule, the 
probabilit}^ of the renal origin is in pro- 

1 Several instructive exceptions have been published : but 
they are only exceptions, and do not invalidate this general 
proposition. 



Ch. VIIL] PERSISTENT ALBUMINURIA . 147 

portion to the amount. It is true, that 
very often the urine of chronic Bright 's 
disease — especially in the cirrhotic kidney 
— contains but a small percentage of 
albumin : but, inasmuch as in such cases, 
the quantit}^ of the twenty-four hours' 
urine is excessive — often four or five pints 
— the aggregate amount of albumin dis- 
charged is really large. 

If the freshly voided urine containing 
albumin — in however small amount — is 
pale, and watery, the observer will sus- 
pect the kidneys : for such is the urine of a 
large number of cases of chronic Bright's 
disease — especially of the cirrhotic form. 
In many cases (as in cirrhosis) the watery 
looking urine is transparent : but in others 
it is not quite clear. 

The observer will bear in mind, that 
the ordinary characters of the urine 
in chronic renal disease are apt to be 
modified by complications — such as 
phthisis, heart disease, inter-current at- 
tacks of pyrexia, and liver derangement 
— the secretion becoming high-coloured, 
and depositing lithates. 



1 48 MINIMA L ALB UMIN URIA . [ch. VIII. 

The non-renal origin of albuminuria, 
even when persistent, is supported by the 
urine — especially that of the twenty-four 
hours — retaining its colour and specific 
gravity. 

III. The quantity of alhumin. 

Besides estimating the percentage, 
or the deposit-proportion, the observer 
should calculate the total dail}^ amount of 
albumin discharged from a sample of the 
twenty-four hours' urine. (See p. 140). 

Tlie quantity is very small: miiii- 
mal altoiimiiiiiria. — The clinical signi- 
ficance of mere traces varies with the 
circumstances of each case. It may be 
trifling, as when the urine contains pus 
cells, blood corpuscles, or spermatic ele- 
ments : but in such cases it is important 
to detect pyelitis — apt to exist in a mild 
form without local discomfort — which 
may be the starting point of chronic renal 
disease, from the inflam.mation insidiousl}^ 
spreading upwards into the kidneys. But 
all cases in which traces of albumin are 
detected in the urine perfectly transparent 



Ch. VIII. ALBUMIN IN RENAL DISEASE. 149 

when voided, require sifting with more 
than ordinary care : for, there may be 
commencing renal disease, or the kidneys 
maybe undergoing cirrhotic degeneration ; 
or it may turn out that such minimal albu- 
minuria is merely ' functional ' (see p. 142). 
Whenever albumin is found in small 
quantity, and some doubt exists as to its 
origin, the observer should always secure 
a sample of the urine passed about two 
hours after breakfast — as this always 
contains the maximum proportion of 
albumin. In investigating doubtful cases 
of albuminuria it is of great practical im- 
portance to avoid alarming the patient 
unnecessarily — as the neurotic disturb- 
ance thus induced may operate injuriously 
on the kidneys (seep. 145). Happily it is 
now well known, that the detec51:ion of 
albumin does not of necessity imply the 
existence of progressive disease of a fatal 
characfter. 

Ttie Qiiaiitity of alfetimiii in tlie 
different forms of renal disease*— 

In actite nephritis after scarlatina the 
amount of albumin is always large : and 



I50 ALBUMIN IN RENAL DISEASE. [Ch. Vill. 

the urine frequently — at the height of the 
disease — soHdifies on boiHng. The per- 
centage, as a rule, varies from -8 to 2*5 : 
and as much as from 100 to 400 grains 
may be discharged in twenty-four hours. 

In chronic renal disease the quantity of 
albumin varies with the form it assumes, 
and the stage it has reached. In chronic 
nephritis (smooth white kidney) albumin is 
discharged usually in large quantity- : e.g, 
from -6 to 2-0 per cent., or from -J- to f de- 
posit in 24 hours ; and the total daily 
amount may reach 300 grains. In the 
cirrhotic kidney the quantity of albumin is 
small : and in the early stage it is said to 
be absent. Often the amount does not 
exceed • i per cent, or -^ deposit : but inas- 
much as the discharge of urine is generally 
excessive, the daily quantity of albumin 
eliminated is greater than the percentage 
suggests ; it generally varies from 50 to 
150 grains. In the waxy kidney albumin 
is, in the early stage of the disease, dis- 
charged in small proportion in a large 
quantity of urine : but, as the disease pro- 
gresses, the percentage as well as the 



Ch.Ylll]. FUNCTIONAL ALBUMINURIA. 151 

absolute amount of albumin increases 
considerably, while the urine diminishes. 
The proportion of albumin will often rise 
from '3 per cent, to 1*5 per cent. : and I have 
noted a rise in the daily amount from go 
to 250 grains. 

In functional alhnmimma (digestive, neu- 
rotic) the amount of albumin is generally 
small — often only from -^ to -^op-c. or even 
less — but in several recorded cases, in 
which evidences of renal disease were 
absent, and the patients recovered, it was 
moderately large. In goitre the quantity 
is often considerable. 

IV. Au' Epitome of the causes of Alhumimiria, 

Tlie causes are often compowiid.— 

In any particular case of albuminuria 
several pathogenic conditions ma}^ co- 
exist. For example, a gouty man commits 
an indiscretion in diet, or is chilled, or is 
excited, or is unusually worried : when 
albumin either appears in the urine, or, 
if pre-existent, increases; and, as the tem- 
porary disturbance ceases, either vanishes 
or diminishes. 



152 THE CAUSES OF [Ch. VIII. 

The following table summarizes the 
principal causes of albuminuria. 

I. THE PRIMARY CAUSE OF THE ALBU- 
MINURIA IS SOME MORBID CON- 
DITION OF THE KIDNEYS OR OTHER 
PART OF THE URINARY APPARATUS. 

{A) The cause is renal. 

Injury : severe contusion of the loins. 

Concretionary Irritation : a calculus, 
or diminutive concretions lodged in 
the tubuli uriniferi. 

Active congestion from 

{a) A chill : e.g,, prolonged cold 
bathing. 

{h) A medicinal irritant: e.g., canth- 
arides, turpentine, carbolic 
acid, salicylic acid, nitrate of 
potash, cubebs, copaiba, &c. 

Acute nepliritis from 
{a) Cold. 

(b) Alcoholic excess. 

(c) Following scarlatina, or other 

febrile or zymotic ailment. 
Chronic Brigtit's Disease, 



Ch. VIII.] ALBUMINURIA. 153 

(B) The cause is referrible to some part of 
the genito-imnary mucous tract. 

Pus or Blood mingling with the urine 
from pyeHtis, cystitis, morbid growth 
(e.g. villous tumour), menstrual flow, 
&c. 

Muco-FuiTileiit Disctiarge from va- 
gina. 

Albeimiiio-Mucous l>iscliarge or Se- 
cretion from th^ prostatic area (sper- 
matic fluid, &c.) 

II. THE ALBUMINURIA IS SYMPTOMATIC 
OF SOME CAUSE AFFECTING THE 
KIDNEYS, BUT OUTSIDE THE URIN- 
ARY APPARATUS. 

Passive Congestion of the Kidneys 

from increased tension in the renal vein, 
as in 

{a) Disease of the heart. 

(b) Emphysema w4th bronchitis. 

(c) Pleuritic effiision. 

(d) Gravid uterus or other abdominal 

tumour (ovarian, aneurismal, 
&c.) 

(e) Cirrhotic liver. 



154 '^^^ CAUSES OF [Ch.vili. 

Fever, 

(a) Zymotic : as in scarlet fever, 
diphtheria, measles, small-pox, 
typhus, erysipelas, cholera, yel- 
low fever, ague, pyaemia, rheu- 
matic fever, &c. 

{b) Inflammatory : as in pneumonia, 

peritonitis, acute articular 

rheumatism, &c. 

f 
Haemolytic and otlter defects of the 

Blood and Tissues. 

{a) The corpuscles tmdergo solution — 
haemoglobinuria, 

(J) HydrcEmic sz^a/'^s-purpura, scurvy, 
chlorosis. 

{c) UriccBmia — gout. 

(d) Poisoning — lead, phosphorus, ar- 
senic, mercury, iodine, mor- 
phia, alcohol. 

{e) Chyluria, lymphuria, (see p. 34). 

(/) Syphilis. 

(g) Tuberculosis, 

Digestive disorders.— Food-albumin- 
uria. Hepatic albuminuria. 



Ch. VIII.] ALBUMINURIA . 155 

(a) Food in excess. Salt in diminished 

quantity. 

(b) Dyspepsia, S'C, 

(c) Hepatic disorders : albuminuria 

induced by the elimination of 
bile-derivatives by the urine, 
(see ch. viii.) 

{d) Oxaluria: as in young men from 
eighteen to thirty.^ 

Neurotic Disturbances. 

(a) Mental worry and over -strain. 

(b) Vascular hronchocele and exoph- 

thalmos. 

(c) After epileptic seizures. 
{d) Delirium tremens. 

{e) Tetanus. 

if) Cerebral hmnorrhage and concussion. 

Cutaneous Irritation : chemical, 
thermic, &c., 

Strangiiilated Hernia* 



i Sir Andrew Clark op. cit. 



CHAPTER IX. 



GLYCOSURIA : 

THE DETECTION OF GLUCOSE BY 

TEST-PAPERS. 



All Alkali necessary-— All the re- 
agents employed as tests for sugar are 
either caustic alkalis, or bodies which 
must be associated with an alkali ; but 
in the latter case it is by no means 
necessary to use a caustic alkali. I have, 
for example, proved b}^ experiment, that 
carbonate of soda will work quite satis- 
factoril}^ w^th mercuric cyanide, picric 
acid, indigo-carmine^ and tartrate of cu- 
prammonium. I have used all these tests 
in the form of test-paper with good and 
reliable results : but the carmine and 
cupric have appeared to me, not only the 
best adapted to this mode of observation, 
but the least open to fallacies. (See pp. 
167 — 176). 

1 In the case of the indigo-carmine test carbonate of soda 
must be used instead of a caustic alkali, which discharges the 
blue colour even in the absence of a reducing agent, such as 
glucose. (See p. 171). 



Chap. IX.] CARMINE TEST SOLUTION. 157 

I. The Indigo-carmine Test-paper. 

The Indigo-careime test-soliitioii 

valueless f^v eliiiical purposes.— 
When a solution of indigo- carmine (the 
sulph-indigotate of sodium), alkaHnized 
by carbonate of soda, is boiled, and is 
then kept heated, the rich blue colour 
remains without change ; but, when a 
drop of a solution of glucose or of 
saccharine urine is let fall into the hot 
solution, there instantly strikes up a 
series of beautiful colour changes which 
culminate in pale yellow. Unfortunately 
for clinical use the indigo-carmine test in 
an aqueous form is valueless ; because, 
when the carmine and the carbonate of 
soda are present in the same solution, the 
test undergoes a gradual change which 
renders it useless — the rich indigo-blue 
slowly giving place to a faded pale green ; 
and, when kept apart as two solutions, 
they must be used on every occasion in 
exactly the same proportions, otherwise 
the results obtained are not comparable, 
and the observer fails to gain a notion 
of the approximate amount of glucose 

M 



158 . INDIGO-CARMINE [Chap. IX. 

present — that useful information, in fact, 
which every good test for cHnical purposes 
should provide. Hence, the liquid pre- 
paration of the test is valueless as a 
clinical instrument ; and the grave defects 
which belong to it must have speedily led 
to the disuse of it by those who followed 
in the wake of Mulder, who introduced it. 

Tlie Indigo-Carmiiie Test-Paper, 
however, not only meets these disad- 
vantages, but amplifies the powders of 
the test. 

(a) Each paper is charged with the 
same definite quantit}^ of the reagents ; 
it thus provides a uniformity for the 
qualitative testing, which also becomes 
a standard of known value for the quanti- 
tative estimation. An additional range 
of sensitiveness is, moreover, provided by 
the paper containing a uniform charge of 
carbonate of soda, when used with the 
ordinary test paper. ^ 

{b) The test-paper furnishes with soft 

1 I prefer the paper in the 'compound' form — the con- 
stituents being kept apart in separate papers united by a 
layer of rubber, which, when heated in water, separates, and 
rolls up to the surface out of the way. 



Chap. IX.] TEST-PAPER. 159 

or distilled water a perfectly transparent 
alkaline solution of the carmine — which 
is, moreover, of a rich blue colour that 
undergoes no change on boiling. On the 
other hand, a transparent solution of the 
indigo - carmine is precipitated by car- 
bonate of soda : and though boiling clears 
up the precipitate, the solution acquires 
a green tint, which is incorrectly de- 
scribed by Mulder, Mehu, Neubauer, and 
Vogel as the first stage of the reaction of 
the carmine with glucose. Unlike the solu- 
tion, the test-paper, therefore, provides a 
clean start for the testing : so that the 
urine to be examined may, with some 
saving of time, be added before heat is 
applied, and the first change of colour, 
which after ebullition gradually appears, 
can be safely taken as the earliest step in 
the reaction. 

{c) The stability of the test-paper is 
beyond question. The constituents being 
dry, remain unchanged ; and, when dis- 
solved out of the paper, they furnish a 
freshly prepared solution at each observa- 
tion. 



l6o INDIGO-CARMINE [Chap. IX. 

Tlie Reaction. — The characteristic 
reaction, which indicates the presence of 
glucose in the urine, arises almost im- 
mediately after a drop of saccharine 
urine is let fall into the hot solution of 
the reagent, prepared from the test- 
paper. A beautiful violet tint suddenly 
spreads throughout the bright blue solu- 
tion ; very quickh^ the violet deepens and 
passes into purple ; this in its turn melts 
into reddish-purple, which gives place 
to various tints of red, and these as 
quickly merge into orange-red and orange, 
and finally the solution becomes of a straw 
colour, which remains without further 
change, though the heating is continued 
ever so long. iVt this point the paper 
assumes the same light yellow colour as 
the liquid. The complete range of this 
striking colour reaction embraces all the 
prismatic colours except green, and the 
order of the appearance of the successive 
hues is always the same. The reaction is 
one of great beaut}^ ; for the primary 
colours are not merely pure and sharply 
defined, but all the transitional and inter- 



Chap. IX.] TEST-PAPER l6i 

mixed tints pass quickly before the eye 
in such richness as one rarely sees in 
nature herself. Now, on shaking the 
tube the colours return in the inverse 
order to that in which they appeared. 
This remarkable thing is not due to cool- 
ing, but to admitting the oxygen of the 
air into the liquid ; for the various hues 
at any stage of the reaction may be 
caught and retained for days, merely by 
corking the tubes full of the solution, and 
the return of the colours, when the test 
tube is at rest, always appears first at the 
surface, and slowly spreads downwards — 
so slowly that after putting the solution 
aside for some hours, at least the lower 
half will still retain its acquired colour.^ 

1 Inasmuch as the return of the colours is clearly due to 
oxidation, it will probably be safe to presume that the re- 
action of glucose on indigo-blue is a process of deoxidation. 
The first stage of the reaction is pretty clearly the conversion 
of the blue (indigotin) into the red (indigorubin) isomeric 
form of indigo — hence the shades of violet, purple and red ; 
and just that small amount of glucose can be added as to 
secure only these steps of the reaction. The second stage 
is the gradual merging of red into pale yellow — the colour of 
indigo-white when dissolved in aqueous alkalis. The whole 
reaction is, therefore, due to the deoxidizing power of glucose 
over indigo-blue in the presence of the alkaline carbonate: the 
blue indigo being converted in the first place into indigo-red, 
and then into indigo-white. 



l62 CARBONATE OF SODA [Chap. IX. 

Experiment has shown that the tint 
reached in any particular observation de- 
pends on the quantity of glucose added to 
the test liquid : e.g., the reaction may 
stop at violet, purple, red, &c., and when 
it thus halts, it can easily be made to pro- 
ceed to the final stage by adding more of 
the glucose-charged urine — an additional 
carbonate of soda paper being added, and 
the liquid the while being kept hot. This 
suggests a principle on which to found a 
mode of quantitative observation. That 
which I employ is a very simple one ; it is 
based on the complete removal of all the 
colours below the pale yellow : and on the 
scale of colours when the quantity of sugar 
is small {e.g., below 5 grains to the ounce). 

Carbonate of §oda Papes's. — Test- 
papers charged with a saturated solution 
of carbonate of soda are provided for the 
following special purposes : — 

(i) When hard water is used. On heating 
the carmine test-paper in hard water a 
clear solution cannot be obtained : for 
the earthy carbonates are precipitated by 
the alkali. Inasmuch as in this reaction 



Chap. IX.] TEST-PAPER. 163 

a portion of the carbonate of soda 
becomes inoperative — passing into the 
bi-carbonate — it is advisable to fortify 
the alkaline charge of the carmine test- 
paper by using a soda paper as well. 
When the water is hard it is best to boil 
the alkaline paper in a measured portion 
of it before adding the carmine test-paper. 
(2) Excessive acidity of the iirine. The 
reader will bear in mind that the acids of 
the urine rob the carmine paper of so 
much alkali : so that the addition of more 
than a certain number of drops of urine — 
varying of course with the degrees of 
acidity — will at first retard and then pre- 
vent the reaction.^ Invariably submitting 
onty one drop of saccharine urine to the 
test-paper, and keeping up the heating for 
not less than two minutes, I have hitherto 
always witnessed the characteristic dis- 
play of colours without requiring to use 
a carbonate of soda paper : so that I 

1 The reaction of solutions of glucose with the carmine 
paper alone can be stopped by adding certain quantities of 
urine of average acidity, e.g., that provided by 40grs. to the 
oz. by about 40 drops of urine ; 2ogrs. by 20 to 25 drops ; 5grs. 
by 7 drops, &c. : but the reducing power of the glucose is 
again restored on adding a carbonate of soda paper. 



164 ^^^ MODE OF USING [Chap. IX 

am led by observation, to regard the 
carmine paper as complete in itself for 
the detection of glycosuria — providing of 
course the observer uses merely one drop 
of the urine delivered from the pipette held 
vertically (see p. 165 — note). But it may 
be well for the reader to bear in mind, that 
a very exceptionally acid saccharine urine 
may perchance be met with, which may 
require also the soda paper. I purposely 
avoided charging the carmine paper with 
more soda than it now possesses, because 
experiment showed me, that it then be- 
came too sensitive for a good practical 
test — one drop of normal urine or of a 
solution of glucose (gr.-J to the ounce) for 
example, then developing a distinct violet 
in the course of heating for two minutes. 

The mode of Testing*. — (i) One of 
the papers should be dropped into the 
half-inch test tube, and then water should 
be poured in to the 6011X mark. 

(2) Heat is applied (see p. 108), the tube 
being gently shaken, and boiling kept up 
for a second or two. The solution will 
then be quite blue ; and, if the water 



Chap. IX.] THE CARMINE TEST-PAPER. 165 

added was soft or distilled, it will be 
perfectly transparent. Any turbidity 
observed will arise from the use of hard 
water : in which case a carbonate of soda 
paper should be dropped into the solution 
(see p. 162J. The test-paper ma}^ now be 
removed, or it ma}^ be allowed to remain. 

(3) Not more than one drop^ of the 
suspected urine is let fall into the tube 
from the pipette, held in an upright 
position. 

(4) The contents of the tube are again 
freely boiled for a few seconds : then 
the tube should be raised an inch or 
two above the flam.e, and held without 
shaking, while the solution is kept quite 
hot, but without ebullition, for exactly 
one minute by the watch. If glucose be 
present in abnormal a.mount, the soft rich 
blue will be seen first of all to darken into 
violet : then, according to the quantity 
of sugar, there will appear in succession, 
purple, red, reddish yellow, and finally 

1 The pipette when held vertically will deliver drops of 
nearly equal size, i.e., about half a minim. But, if the drop 
is allowed to fall from it in a slanting position, it will be 
larger, and more liable to variation in size. 



1 66 THE MODE OF USING [Chap. IX. 

straw yellow. When the last named 
colour has been developed, the observer 
will find the slightest shaking of the tube 
will cause red streaks to fall from the 
surface, and to mingle with the pale 
yellowness of the solution ; and further 
agitation will, of course, cause the return 
of purple and violet, and the restoration 
of the original blue. 

The time required for the commence- 
ment of the reaction after the boiling of 
the test liquid, varies in inverse proportion 
to the amount of glucose present : when 
the latter is large — e.g., over 20 grains to 
the ounce — it will extend only to a few 
seconds ; but when small — e.g., from 2 
or 3 grains to the ounce — from thirty to 
sixty seconds ma}^ elapse. 

If the urine does not contain more 
than the normal amount of sugar — i.e., 
under half a grain to the ounce — the 
colour of the solution at the end of the 
heating for one minute, will be unchanged. 

Care should be taken during the obser- 
vation not to shake the tube, or to keep 
up free ebullition. There is besides 



Chap. IX.] THE CARMINE TEST PAPER. 167 

another precaution against which the 
observer, who has no practical experience 
of this test, should be warned : while 
keeping the contents of the tube hot, he 
should not hold the latter up between his 
eyes and the sky — for then the early 
colour changes may escape observation ; 
but he should keep it below the eye-level, 
and view its contents by the reflected 
light of some bright object, such as a 
sheet of white paper propped up an inch 
or two beyond the tube, as a back-ground. 

The test is as available by artificial as 
it is by daylight. 

Confirmatic^n of results toy Fetiling's 
solution. — In applying the test-paper to 
different urines, I took Fehling's solution 
as my guide, because it is the best known 
glucose test. 

The results of the working of the two 
side by side were briefly as follows : — 

{a) On always submitting one drop of 
urine to the indigo test, and the presence 
of sugar being shown, confirmation was 
invariably provided by Fehling used in 
the ordinary way. 



1 68 EXPERIMENTAL TESTINGS [Chap. IX. 

(b) On the other hand, whenever one 
drop of urine gave no reaction with the 
test, Fehling's solution did not give the 
cuprous precipitate. 

ExperiiMeiital Testing^s witli tlie 
Iiadig^-Cariiiiiie Test-Paper and with 
Felilmi''s Solution compared. — In the 
last edition of this work I gave in 
detail a large number of experimental 
observations on the reduction of these 
glucose tests by various agents — certain 
urinary constituents, and medicinal sub- 
stances which may appear in the urine. At 
that time the somewhat uncertain clinical 
position of the indigo-carmine test-paper 
required such a critical examination : but 
now, inasmuch as that uncertainty is being 
removed by experience of the test, and 
the practical value of it is being realized, 
there no longer remains a sufficient need 
for the same scrutiny in elementary data. 
I will, therefore, merely give an epitome of 
my observations relating to these matters. 

(a) The urmary constihients. — None of the 
ordinar}'^ constituents of the urine affect 
the carmine test, but all the free acids of 



Chap. IX.] WITH CARMINE &-■ FEHLING. 169 

the urine — uric, oxalic, lactic, &c., — 
reduce Fehling's solution. 

Of the substances apt to appear in the 
urine in disease, albumin, peptone, pus, 
mucus, bloods bile, leucin and tyrosin do 
not react with either test ; but dextrin and 
milk sugar as well as glucose reduce both. 

The carbohydrate, inosit, which has 
been detected in small quantity in the 
urine of some cases of diabetes and 
albuminuria, reacts with the carmine, and 
turns Fehling's solution green — a green 
precipitate falling, leaving the superna- 
tant liquid blue, but becoming green on 
reheating. Hence, Dr. Ralfe points out 
that the indigo-carmine test '' may be 
thus made available for distinguishing 
between those forms of sugar sometimes 
present in urine which give no reaction 
with copper, and which do not readily 
ferment, and so help to distinguish those 
cases from true glycosuria. "^ 

It has been suggested to me that stale 
urine — which is the favourite reducing 

1 The sugar contained in these fluids may reduce the tests. 
^ Clinical Chemistry, p. 155. 



I JO EXPERIMENTAL TESTINGS. [Chap. IX. 

agent of some wool-dyers — may afford the 
reaction; one of the advantages, however, 
of this mode of testing is the avoidance of 
decomposing urines, with which no test 
for glucose can be trusted. I have, how- 
ever, observed that the test-paper does 
not produce a reaction with one drop of 
ammoniacal urine, or of decomposing 
albuminous urine ; and ammonium sul- 
phide in weak solution (but sufficient to 
reduce Fehling) used in the same way is 
equally negative, but, when more con- 
centrated, it will reduce the carmine. 
When ammonia is freely added to diabetic 
urine, the reaction is not retarded or 
prevented ; and ammonia of itself cannot 
produce it. But still I would suggest 
some caution in inferring the presence of 
sugar in putrifying urine from the reaction 
with the carmine test-paper, or with any 
test for glucose. 

{b) Of medicinal agents likely to find their 
way into the urine, the only ones which 
react with the carmine are iron sulphate,^ 

1 " Salts of iron, especially augment very largely the iron of 
the urine, though the amount passing off in this way is not 



Chap. IX.] CARMINE & PICRATE TESTS. 171 

and gallic and tannic acids — substances 

which likewise reduce Fehling's solution. 

Clinical and experimental resnlts 

provided fey tlie Carmine and l>y 

tlie Pier ate of Fotasli Tests. — In all 
my observations on these elementary 
data, as well as in my clinical experience 
during the past two years, whenever the 
indigo-carmine test-paper afforded a re- 
action, a corresponding one was obtained 
by the picrate of potash solution. The 
picric, as well as the carmine test, reacts 
with all other forms of carbo-hydrates 
besides glucose, that may appear in the 
urine — such as dextrin, lactose, maltose, 
and inosit. 

There is one substance which — though 
not a constituent of the urine — will dis- 
charge the blue colour of the carmine : 
and that is a caustic alkali — Liq, Potasses 
vel SodcB, I think it w^ell to mention this, 

known." The Composition of the Urine, &c., by Ed. A. 
Parkes, M.D,, Lond., i860, p. 142. I have found the urine of 
patients taking iron freely is apt to give reactions with the 
Gupric, and carmine tests, suggestive of small quantities of 
sugar over the normal amount. In this connection the 
observation of Graevecke, that iron in the urine is always 
in the ferrous condition, is instructive. — (Archiv. f. Exp. 
Pharm., vol. xvii., p. 466). 



172 CLINICAL ADVANTAGES. [Chap. IX. 

lest the observer, using a test tube con- 
taining a trace of Fehling's or the alka- 
hne picric solution, obtain a. reaction with 
a drop of non-saccharine urine. The 
caustic alkali converts the blue carmine 
into a green solution ; and on heating all 
colour gradually vanishes. This reaction 
is, furthermore, unlike the characteristic 
one afforded by glucose, in that any 
remaining colour after heating slowly 
fades away on shaking the contents of 
the tube ; and, when the solution has 
become quite colourless, no amount of 
agitation will restore the colours. 

S§oaiie Clinics^l adv£B^iitag^ei§ of the 
Indigo - Carmiiae Test - Paper. — The 
high position of Fehling's solution as a 
test for glucose in urine cannot be 
questioned ; but for two disadvantages 
which belong to it — the liability to 
change on exposure to light and air, and 
the caustic properties which condemn it 
for bedside or out of door work — no one 
would desire a substitute. It has un- 
doubtedly yet much sound work to do, 
and I have no wish to disparage it. Still, 



Chap. IX.] OF THE CARMINE TEST-PAPER. 173 

like every other urinary test, it is not 
equally good all round. Where it is weak 
and apt to fail, the indigo-carmine test, 
as here presented, appears to me to supply 
useful supplemental aid — apart from other 
clinical advantages. 

(i) Sugar in small quantity along with 
much albumin, may be overlooked by 
Fehling. The search for sugar by this 
test in albuminous, bloody, or purulent 
urine, should be preceded by the pre- 
cipitation of the albumin, and by filtration. 
These procedures are, however, unneces- 
sary when the indigo-carmine test-paper 
is used ; for, it has been proved by re- 
peated observation, that it will detect 
sugar — in any proportion, and as readily 
as in ordinary diabetic urine — in the 
presence of albumin, peptones, blood, pus, 
&c. 

(2) It is well known that uric acid will 
reduce Fehling's solution : but this body 
does not react with the carmine test. 
The latter is unaffected by urates : the 
former is, however, apt to give with them 
a cuprous precipitate, which may easily 

N 



174 CLINICAL ADVANTAGES OF [Chap. IX. 

lead to a false inference. On this point 
Prof. Cameron, of Dublin, gives the fol- 
lowing very useful caution in applying 
the cupric test. " I occasionally find 
urine with a very high specific gravity, 
and with a, so to speak, diabetic appear- 
ance, to be quite free from sugar. On 
several occasions, in specimens of urine 
believed to contain sugar, I could not 
detect a trace of that substance. A few 
months ago I examined the urine of a 
man who had been treated for diabetes. 
The urine had a specific gravity of 1035, 
and, on being boiled with Fehling's solu- 
tion, it gave a copious precipitate of 
cuprous oxide. There was something in 
the appearance of the precipitate, and in 
the slow way in which it made its appear- 
ance, that led me to suspect that it was 
not produced by sugar. This proved to 
be the case, for on treating the urine with 
yeast no carbonic acid (save a mere trace) 
was evolved. The presence of large 
quantities of urates in urine causes a 
brown precipitate with Fehling's solution. 
The urates, even when abundant, do not 



Chap. IX.] THE CARMINE TEST-PAPER. 175 

always separate as the characteristic 
* brick-dust.' I have found very large 
quantities of urates of ammonium in urine 
which remained clear on standing, but 
which gave a brown precipitate on being 
boiled with Fehling's solution." (Dublin 
Journal of Medical Sciences, April, 1883). In 
such cases the clinical value of an appeal 
to the carmine test must be apparent ; for 
it will in a ready and simple way obviate 
the fallacy which makes the cupric test 
untrustworthy. 

(3) Dr. Ralfe has suggested (see p. 169) 
that it may prove a valuable supplement 
to the other tests for sugar, by virtue of 
its power to detect the saccharoid bodies 
which may appear in the urine that do 
not react with copper, or that do not 
readily ferment. The reader will, how- 
ever, bear in mind that hitherto observa- 
tion has shown that such bodies — e.g., 
dextrin, lactose, inosit, — but rarely appear 
in the urme ; and that, therefore, when the 
reaction is obtained with the carmine the 
presence of glucose may be pretty safely 
inferred. 



176 THE CUPRIC TEST-PAPER. [Chap. IX. 

(4) The capacity of the carmine test- 
paper to afford information as to the ap- 
proximate quantity of sugar in the course 
of the search for this body (see Chapter 
X.) is a valuable working property ; for it 
enables the practitioner at once to form 
an estimate of the cases of glycosuria 
examined for the first time, and of the 
effects of treatment — so far as these 
can be gauged by the amount of sugar 
excreted. 

(5) The stability of the handy and 
cleanly carmine test is an unquestionable 
gain : though this property belongs in an 
equal degree to the cupric test-paper. 

II. The Cupric Test-paper. 

The Cupric test-paper.— A large num- 
ber of observations and experiments have 
shown me, that the only cupric salt that 
can be selected as the reagent of a reliable 
test for glucose in the form of test-paper, 
is the tartrate of cuprammonium : and it 
is remarkably well fitted to serve this end, 
for it is the onl}^ compound of copper that 
is permanent on exposure to the air, and 



Chap. IX.] THE CUPRIC TEST-PAPER. 177 

moreover, the only one that is stable 
when boiled with an alkaline carbonate — 
as well as with a caustic alkali ; no 
cuprous oxide falling until a reducing 
agent — such as glucose — is added. I 
have now kept test-papers, charged with 
the cuprammonium tartrate, continuously 
exposed to light and air for considerably 
over twelve months, without the slightest 
change : their glucose-detecting power 
remaining as definite as when the papers 
were freshly prepared. 

The test-paper is a compound one : 
consisting of two papers combined by 
a layer of rubber — one charged with the 
reagent, and the other with carbonate of 
soda. Experiment has shown that in 
order to secure the requisite degree of 
sensitiveness, the constituents must be in 
definite proportions. 

The reaction. — When the test-paper 
is dropped into 60TIX of soft or distilled 
water, and heat is applied to the boiling 
point — the boiling being kept up for a few 
seconds — a greenish tinted solution is 
obtained, which is perfectly transparent, 



178 THE CUPRIC TEST-PAPER. [Chap. IX. 

and will remain quite clear, though boiled 
for ever so long. This fact — non-reduc- 
tion b}^ heat — of course proves the re- 
liability of the test. As the observer lets 
fall a drop of saccharine urine into the 
solution, left quite hot on the withdrawal 
of the flame, he will not note an}^ im- 
mediate change : but in a few seconds 
there will suddenty break out in the body 
of the clear liquid whitish streaks, that 
quickly develop into a diffused uniform 
opacity of a light colour. Renewed boil- 
ing deepens the opalescence, which then 
acquires a yellowish tint. The reaction 
is, therefore, not a precipitate, like that 
which falls when Fehling's solution is 
reduced. 

When glucose is present in but small 
quantity — from i to 3 grains in the 
ounce — the opacity is not only longer in 
appearing, but is of lighter colour, even 
after thorough boiling, than when the 
urine is more saccharine. Observation 
has shown, that when, after adding one 
drop of the suspected urine, the solution 
is kept on the boil, a whitish haze or 



Chap IX.] THE CUPRIC TEST-PAPER, ijg 

opacity will appear towards the close of a 
minute, if glucose is present in the small 
proportion of from i to i J gr. per ounce. 
l>irectioits. — i. Drop a test paper 
into 6orrL of soft or distilled water. ^ 2. 
Boil for a few seconds until the water 
assumes a greenish tint. 3. Extract the 
papers. 4. Re-boil the solution, and 
then add one drop of the suspected 
urine. 5. If glucose be present, reduction 
will take place without the further appli- 
cation of heat — though, if the observer 
prefers, he may continue the boiling, and 
thus hasten the reaction. In any case, if 
the solution remains transparent for a 
quarter of a minute, heat should be 
applied to the boiling point for one 
minute ; if, then, no opacity whatever 
appears, it may be safely inferred, that 
glucose in pathological proportions is 
absent. 

1 If the water employed be hard, the solution prepared 
from the test-paper will be milky from precipitated earthy 
carbonates : if such water be used at all, it should be boiled 
first of all with a carbonate of soda test-paper, but even then 
it should not be used for delicate testing. Where the 
drinking water is hard, rain water should be used. 



CHAPTER X. 



GLYCOSURIA: 
QUANTITATIVE GLUCOSE. 



Tlie Indigo - carmme Test - Paper 
provides quantitative intormation.— 

A most desirable property of a qualitative 
test at the bedside is the power to furnish 
a good notion of the coarser variations of 
quantity ; for, this knowledge obtained 
on the spot, must often be of greater 
utility than the discovery of the finer 
gradations by methods of precision, 
which are not available beyond the con- 
sulting room, and necessarily require 
time for their application. It is this 
practical quality which emphasizes the 
adaptability of the carmine test-paper to 
bedside work. But inasmuch as almost 
every saccharine urine provides pretty 
uniformly the complete reaction — the 
final pale yellow being nearly always 
reached — the observer will scarcely be 



Chap.X.] CARMINE QUANTITATIVE. i8l 

prepared to regard the test-paper in a 
quantitative light. 

A Httle observation will, however, soon 
show, that this aspect of it is not onty 
capable of verification, but can be readily 
applied in practice. 

When the attention has been directed 
to the degree, and to the rapidity of the 
reaction w4th different saccharine urines, 
great variations are to be observed. In 
some, for instance, it begins immediately 
after the drop of urine has fallen into the 
hot solution, and is perhaps completed in 
half a minute ; while in others, the com- 
mencement of it is delayed for twenty or 
thirty seconds, and pale yellow is not 
reached until even tw^o minutes have 
elapsed ; and in still others, at the end of 
the prescribed time for heating — 120 
seconds — the colour developed is perhaps 
only red, purple, or violet. 

The cause of all this variability is 
found to be the different proportions of 
glucose present. This fact I have proved, 
not only by quantitative estimations by 
Fehling's solution, but by dissolving glu- 



1 82 THE CARMINE TEST-PAPER [Chap. X. 

cose in normal urine, and in distilled water, 
and submitting — as with saccharine urine 
— one drop of each solution to the test. 
The reaction — both in the degree it 
attained in the specified two minutes, and 
the rapidity of it — was always pro- 
portionate to the amount of glucose. For 
instance, less than five grains to the 
ounce would not develop the final colour 
— pale yellow — at all within two minutes, 
while lo grains did so within one minute, 
and 35 or more grains within thirty 
seconds. 

Glucose always afforded the same 
reaction, whether dissolved in the urine 
or in distilled water. I therefore conclude, 
that none of the non-saccharine con- 
stituents of the urine are causes of 
variation. Excessive acidity of the urine 
may, however, in some cases diminish 
the reaction ; but, inasmuch as from ten 
to twelve drops of normally acid urine 
are required to appreciably retard the 
reaction of a solution of glucose (20 
grains to the ounce) on the carmine 
paper, it is pretty clear, that the acidity 



Chap. X.] Q UA NT IT A TIVE. 1 83 

of a urine must rise ver}^ considerably 
over the average, before it can become a 
source of disturbance. But, inasmuch 
as saccharine urines are highly acid, and 
more particularly so after the lapse of 
a few hours, it will be as well to elimi- 
nate this possible cause of variation 
of the reaction, by adding on all occa- 
sions a carbonate of soda paper to a 
definite portion of the urine to be 
examined.^ 

On diluting saccharine urines further 
evidence of the quantitative power of the 
test-paper is apparent, the reaction being 
delayed or rendered incomplete — as the 
case may be — in proportion as water is . 
added to the urine. (See p. 189). 

The Mode of Testing-,— The direc- 
tions for the qualitative testing (see p. 164) 
are to be followed, but with more care in 
certain particulars. 

(i) The water to be used should be 
distilled or soft. 

(2) The quantity of water to be added 

1 There is sufficient soda in each carmine paper' to 
neutralize at least forty minims of urine of average acidity. 



184 THE MODE OF [Chap. X. 

should not exceed the 6onx mark on the 
half-inch test tube. A wider tube than 
this should not be used. 

(3) Tv^^enty minims of the urine to be 
examined are shaken with a carbonate of 
soda paper in the larger test tube, which 
is then set aside. 

(4) The observer should select, if pos- 
sible, daylight ; and he should place some 
light coloured object close behind the 
tube, so that he may view the colour 
changes distinctly by a bright reflected 
light. The disappearance of red is, how- 
ever, perhaps most easil}- detected by 
holding the tube against the sky. 

(5) Before the testing is begun the ob- 
server lays before him his watch — a 
centre seconds is by far the best for the 
purpose. Time is to be accurately esti- 
mated by the seconds hand. 

(6) Immediately after the paper — which 
is allowed to remain — has been boiled, 
when the carmine has well passed into 
solution, and when the liquid is quite hot, 
one drop — not more — of the urine in 
the larger test tube is delivered from the 



Chap. X.] QUANTITATIVE TESTING. 185 

pipette held vertically,^ and the exact 
time by the seconds hand of the watch 
is noted. 

(7) The solution is then well boiled up 
for about 10 seconds, and the tube is 
raised a few inches above the flame, and 
is very steadily held in that position; 
but on the slightest ebullition occurring, 
it is raised still higher. The prevention 
of simmering during the course of the 
heating is a most important precaution 
towards obtaining reliable comparative 
results. The slightest shaking of the 
tube — especially towards the end of the 
reaction — should be avoided. 

(8) If the complete reduction, indicated 
by pale yellow, is not effected within two 
minutes, the heating is kept up for the 
whole of this period. 

1 I am aware that a drop is a somewhat variable quantity : 
it is, however, I think preferable — in handiness and practic- 
ability — to the minim, the accurate measurement of which 
requires well trained and reliable eyes and fingers, unfortu- 
nately not possessed by all ; and the variability of the drop, 
when discharged from the pipette held in a vertical position, 
is not so great as to disturb the conclusions of the text. 
Those who prefer a more precise method will find it con- 
venient to take lom of the urine, and make up with water to 
loom, add a carbonate of soda paper, and use 5n'i; at each 
testing. 



1 86 QUA NT IT A TI VE DA TA . [Chap. X. 

The carbonate of soda paper should on 
no account be used along with the car- 
mine test-paper, which is complete in itself. 

From the time of dropping in the urine 
the observer should specially note the 
colour of the solution at the close of 

(a) Thirty seconds. 

(b) One minute. 

(c) Two minutes. (See diagram p. i88). 
Quantitative data.— The quantitative 

information to be derived from the test- 
paper is obtained from submitting to it 
the urine, (i) undiluted, and (2) definitely 
diluted. 

I. The Urine undiluted. 
The data provided fall into two sec- 
tions : according as the reaction is com- 
plete or incomplete at the expiration of 
the period prescribed for heating — two 
minutes. 

(a) The reaction is incomplete. — When the 

final colour change — pale yellow^ — is not 

developed, there are less than 5 grains of 

sugar to the ounce, or under i per cent. 

Any vestige of red tinging the yellow 



[Chap. IX. Q UA NTITA TIVE DATA. 187 

can be distinctly seen, when the tube is 
held without any shaking about an inch 
before a piece of white paper : on, how- 
ever, placing it immediately against the 
latter, a trace of red may still be detected 
— to remove this requires not less than 
10 grains to the ounce. 

When sugar is present in smaller 
quantity than 5 grains to the ounce, the 
colour of the solution at the end of the 
heating for two minutes represents definite 
quantities. 



Colour. 

Violet^ 


Grains to the ounce. 

= about I. 


Purple^ 

Red 

Reddish Yellow 


= ,, 2. 



If violet does not appear within half-a- 
minute, there are less than 2 grains of 
glucose to the ounce. 

If the solution, however, retains its 
blueness for twenty or thirty seconds, and 
then during the course of the first minute 
becomes violet and purple, the quantity 

1 The casual observer is apt to confound violet with 
purple: but the colours are quite distinct — the former having 
blue, and the latter red, as the predominating hue. 



l88 QUANTITATIVE DATA. [Chap. X. 

of sugar is about 2 grains to the ounce : 
but if the violet appears at the close of the 
boiling up for ten seconds, there are at 
least from 4 to 6 grains to the ounce. 

(b) The reaction is complete, — The time re- 
quired for the full development of all the 
colours is determined by the amount of 
sugar. 

When straw yellow is reached in 

Grains to the ounce. 
J a minute there are about 35 grains or more. 

1 M M M ,, 10 

2 minutes ,, ,; ,, 5 









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/ / ^ 


^ 


\ 


/^ s 


x^ 


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'7 $ 


% 


A 


-^ 


^ 


CR 


n ^ 





^ 


, "absec. (^ 


^90 sec. 


i 


^ ^ ^ 


^ 


y 


\ V ^ 


c 
^ 


/ 


x" 


5 s^>-^ 


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Chap. X.] QUANTITATIVE DATA. 189 

The observer should carefully note the 
rapidity of the reaction in the course of 
the first minute. If at the close of the 
first half of it the solution is reddish, the 
quantity will be less than 35 grains to the 
ounce : but if it is pale yellow, the amount 
will be larger than this. If at the termina- 
tion of the minute a red tinge is still 
apparent, the proportion will be under 10 
grains to the ounce, or below 2 per cent. 

2. The urine definitely diluted. 

When the reaction with the undiluted 
urine is completed within one minute, 
only a general conception of the quan- 
tity of sugar is provided by the test- 
paper. But the information thus ob- 
tained is a useful preliminary to the 
acquirement of a more definite idea of 
the amount, which can be attained by the 
further testing of the urine methodically 
diluted. 

The principle of the procedure is to 
take a measured portion of the saccharine 
urine (20TIX) and to dilute by the same 
volume (20111) of water at a time, until at 

o 



I90 QUANTITATIVE DATA. (;chap. X. 

last it is found, that at the conclusion 
of the heating for the definite period of 
one minute, the colour developed is no 
longer pale yellow, but has a distinctly 
red tinge ; the approximate amount of 
sugar is then arrived at, b}- multiplying 
the number of times the volume of the 
urine was increased on the previous dilu- 
tion by lo grs. to the ounce. In this way, 
when urines are found to contain more 
than this amount of sugar, they are 
uniformly reduced to it ; and the dilution 
is continued until it is clear the limit 
has been overstepped — a reddish hue 
remaining at the close of the procedure. 
On returning the urine contained in 
the pipette to the large test tube into 
which 20T1X were delivered (see p. 184), 
the observer adds the same measure of 
water. If, however, on testing the un- 
diluted urine he found the yellow to 
appear at the end of half a minute, he 
may at once dilute the urine to three 
times its volume (second dilution), other- 
wise he will only add 207ix of water, and 
re-test. If, at the termination of the 



Chap. X.] Q UA NT IT A TI VE DATA. 191 

minute the yellow still appears, the 
contents of the pipette are returned to 
the test tube holding the diluted urine, 
and a further addition of 2onx of water is 
made. The testing is repeated ; but, 
when it is evident the complete redu(5lion 
of the blue carmine is not accomplished 
at the expiration of the minute, the 
procedure is at an end. 

On putting this method into pracflice 
under the guidance of Fehling's quanti- 
tative determination, I find, that when 
the testing by the carmine paper affords a 
reddish yellow tint, the value of the last 
dilution should be counted as five grains ; 
which amount should be added to the 10 
grain values of the previous dilutions ; 
but, when the final trial provides a more 
decided red colour the calculation should 
only include the previous dilutions. For 
example : a urine containing according to 
Fehling 7 p, c. of sugar, or about 36 grains 
to the ounce, on the second dilution, gave 
at the expiration of the minute a reddish 
yellow reaction ; therefore, the amount 
was 3 X 10 + 5 = 35 grains to the ounce* 



192 CA RMINE TEST-PA PER . [ Chap. X. 

Another urine, shown by Fehhng to con- 
tain 6 p, c, of sugar, or about 31 grains to 
the ounce, just reduced the carmine on 
the second dilution, but on the third it 
failed in doing so, and the solution, on 
being heated for the minute, merely 
acquired a redness that could not be 
mistaken for yellow ; the calculation was, 
therefore, 3 x 10 = 30 grains to the ounce. 

The determination of sugar by this 
method does not usually require more 
than three test-papers in all (often two 
will suffice), and the expenditure of more 
time than five minutes. 

Conclitsioiis. — (i) The indigo-carmine 
test-paper enables the clinical observer to 
discriminate between the glucose charges 
of different saccharine urines in the course 
of the mere qualitative testing. 

(2) It furnishes definite, though only ap- 
proximative, quantitative data ; sufficient, 
however, for most of the clinical require- 
ments of the practitioner. 

(3) The method proposed for its quanti- 
tative use exacts but a small expenditure 
of time — only a few minutes — and merely 



Chap. X.] CONCLUSIONS. 193 

that careful attention to a few essential 
details, and the ordinary skill in observing 
and manipulating which it is rightly 
presumed that most medical men possess. 



CHAPTER XL 



GLYCOSURIA: 

THE CLINICAL SIGNIFICANCE OF 

GLUCOSE. 



Crlycosuria is not synonymoiis 

witli diabetes inellitus. — The fact is 
not sufficient^ recognised by practi- 
tioners, that the presence of gbjcose in 
pathological proportions in the urine 
does not necessarily imply the existence 
of saccharine diabetes : any more in fact 
than does the detedlion of albumin in 
the urine signify renal disease. 

The glycosuria is intermittent.— 
As in albuminuria, so in glycosuria, it is 
of clinical moment to discover if the 
constituent in morbid proportions is only 
present while digestion is going on, and 



Chap. XL] INTERMITTENT GLYCOSURIA. 195 

disappears in the hours of fasting. If in 
any case this relation can be distindl:ly 
made out, the disorder is in all proba- 
bility not truly diabetic. Dr. Lauder 
Brunton has pointed out, that simple 
temporary glycosuria very often occurs 
in perfecftly healthy persons.^ " If you 
will examine the urine of several healthy 
persons a couple of hours after breakfast, 
it is highly probable that you will find 
distin(5l evidence of sugar ; for breakfast 
is a meal at which a much larger pro- 
portion of bread is eaten than at other 
meals, and at which, not unfrequently, 
a good deal of sugar is taken along with 
tea or coffee. "^ 

Glycosuria of this type will become re- 
mittent, instead of being merely temporary 
or confined to the period of digestion, if 
the meals follow each other before the 
sur-charge of sugar in the blood is cleared 
away — then the urine will contain the 
largest amount of glucose when digestion 

1 Art. Diabetes by T. Lauder Brunton, M.D., F.R.S. 
Reynolds' System of Medicine. VoL v. 
■ 2 Lettsomian Lectures, 1885, on Disorders of Digestion by 
Dr. Lauder Brunton, 



ig6 INTERMITTENT GLYCOSURIA. [Chap. XI. 

is at its height, and the least quantity — 
always some — before meals. ^ 

These forms of digestive glycosuria are 
not uncommon among the elderly and the 
gouty ; and the}^ have, moreover, been 
observed when the portal vein is occluded, 
as in p3dephlebitis or in cirrhosis. They 
are apt to appear also when sugar is taken 
in excess, or when the digestion of starch 
is too rapid, and the glucose thus fur- 
nished is absorbed too quickly. 

Temporary glycosuria has been re- 
corded after an epileptic seizure, or a 
convulsive fit of hysteria ; during or after 
a paroxysm of ague ; after an attack of 
asthma, or whooping-cough ; after inhala- 
tion of carbonic oxide, ether, and chloro- 
form ; during an attack of sciatica ; after 
injuries of the cerebral lobes, or of the 
spine from concussion ;2 after operations 
on the abdominal cavity ; during the 

1 The reader will bear in mind, that in diabetes mellitus — 
as with the albumin of renal albuminuria — the quantity of 
glucose rises considerably after meals, and diminishes during 
fasting : when, however, it is still present as a rule, in Con- 
siderable amount. 

2 Several cases of temporary traumatic glycosuria are on 
record. 



Chap. XI.] DIABETES MELLITUS. igy 

lodgement of a tapeworm in the intes- 
tines ; and in the course of the recovery 
from cholera. Probabty also neurotic 
excitement and worry induce it : we then 
obtain the so-called ' glycosuric storm' 
from over-strain, resembling temporary 
albuminuria from the same cause. 

The urine of temporary glycosuria dif- 
fers from that of saccharine diabetes, in 
being of normal quantit}^ and appearance, 
and in furnishing a specific gravity not 
unusually high. 

The Crlycosi-ai'ia is persistent.— 
This is the essential feature of diabetes 
mellitus.^ The characters of the urine are : 
quantity excessive^ ; glucose from i to lo 
or even 15 p. c, and furnishing a daily 
discharge which ranges from ^ an ounce 
to over 2 pounds ; specific gravity high — 
generally from 1030 to 1050; colour pale 
and bright ; odour peculiar — often whey- 
like ; acidity generally high ; and, when 

1 The glucose may, however, greatly diminish or even 
vanish, during intercurrent febrile attacks, on the approach of 
death, and in prolonged fasting : and it may disappear under 
dietetic treatment. 

2 When the daily discharge of urine does not exceed loo 
ounces the obvious properties of the urine are normal. 



igS DIABETES MELLITUS. [Chap. XI. 

it soils the clothes, it leaves a white 
deposit of sugar. When kept for a 
few hours in a warm room, diabetic 
urine becomes turbid from fermentation 
products — carbonic acid gas, and the 
spores and filaments of the yeast plant. 

In advanced cases of diabetes, the 
urine is apt to become albuminous from 
degeneration of the kidneys. 



CHAPTER XII. 



CHOLURIA: 

THE DETECTION OF BILE-DERIVATIVES 

IN THE URINE. 



The Biliary Elements wliicli may 
appear in tlie Urine. — Two kinds of 
liver-derived products are met with in 
urine : one, the bile-pigment ; and the 
other, colourless — the biliar}^ salts. 

I. The Bile-pigment. 
Tisnal characters of the Urine. — 

The bile colouring matter alwa^^s darkens 
the urine, and communicates to it a yel- 
lowish brown or brownish red colour, or 
even a shade as dark as that of porter. 
On shaking up the urine, the observer 
will note, that the froth is yellow : and 
on dipping a piece of filtering paper 
or linen into the urine, it acquires a 
yellow stain :^ see the patient's shirt. 

1 The observer may thus conveniently take home some of 
the bile-pigment for examination : for the dried filtering paper 
will readily deliver up its bile-charge to water. 



200 THE BILIARY SALTS [Ch. XII. 

Very dark bile- charged urines differ from 
other deep coloured urines, by becoming 
brownish red or yellow on being diluted. 
Tlie KeactioM witli a Citric test- 
paper.— The test-paper is placed on the 
blade of a knife, and two drops of the 
urine are let fall upon it ; heat is applied 
gradually, and before the paper becomes 
dry, it turns green or greenish — from bili- 
verdin induced by the action of the acid 
on the bile pigment — if the dark colour 
of the urine is due to biliary colouring 
matter : otherwise the appearance of the 
paper undergoes no change. A slight 
reaction is increased by repeating the 
testing. Care, of course should be taken 
not to char the paper. 

II. The Bile-salts, 

Tlie Urinary Derivatives of the 
Biliary Salts, — The salts of the bile- 
acids, as the}^ exist in the bile, are tauro- 
cholate and glycocholate of sodium — the 
former greatly predominating. These 
biliary constituents are not altogether 
eliminated by the kidneys in the chemical 



Ch. xn.] IN THE URINE. 20 1 

forms in which the}^ are secreted by the 
liver. When the}' reach the intestines, 
they are split up into taurin and glycin 
on the one hand, and cholate of sodium 
on the other. The cholate is mainly re- 
absorbed by the bowels : a small portion 
only being excreted in the faeces ; while 
the rest is returned to the liver by the 
portal blood, and is, at least in part, 
eventually discharged in the urine (see p. 
223). The bile-salts, as they appear in the 
urine, consist of the liver-secreted salts — 
taurocholate and glycocholate — and of 
the derived salt — cholate. 

Tlie Clinical Tests liitlierto em= 
ployed foF detecting" Bile-Salts in 
tlie Urine are nnsatisfactory»— All the 
works on physiology and on urine refer 
to Pettenkofer's test — sulphuric acid and 
cane sugar — or some modification of it, 
as the onh^ clinical means by w^hich 
bile-acids are to be detected in the urine. 
However satisfactory this test may have 
proved itself in the hands of chemists, 
who have applied it to solutions of the 
bile - acids extracted from the urine, it 



202 PETTENKOFER'S TEST [Ch. XII. 

cannot, I am fully persuaded, claim an 
analagous position as a mode of direct 
testing — such as the practitioner requires ; 
for my experience of it as a clinical test 
has been most disappointing. In delicacy 
it falls far short of the clinical needs of 
the practitioner ; and in reacting with 
other substances besides the bile-deriva- 
tives — e.g., albumin, and other organic 
bodies — it is apt to mislead the observer. 
I can, therefore, endorse Dr. Tyson's re- 
marks on this point. — '^ From a perusal 
of almost all the text-books on physiology, 
and even of numerous manuals on the 
examination of the urine, the student is 
led to suppose that the detection of bile- 
acids, if present in the urine, by means 
of what is called Pettenkofer's test, is 
one of the easiest possible. On the other 
hand, nothing is farther from the truth, 
and the fact is that such detection by the 
direct application of the elements of Pettenkofev'' s 
test to urine, or any other animal fluid, is prac- 
tically impossible, even if the bile- acids are 
present in considerable amount* Nor have 
any of the modifications of Pettenkofer's 



Ch.XII.] !S UNSATISFACTORY. 203 

test, recently announced as clinically 
available, proved such in my hands, even 
where the elements of bile have been 
added to the urine, except where inspis- 
sated ox-bile has been used." — The italics 
are Dr. Tyson's. [Op. cit. p. 91). 

I am disposed to conclude from my 
observations that Pettenkofer's test does 
not react directly with the liver-secreted 
salts — taurocholate and glycocholate — 
but only so with the derived salt — cholate. 
Hence, it does not indicate the presence 
of the biliary salts in fresh ox-bile until 
it has had time to decompose them, and 
thus to liberate cholic acid : but it reacts 
at once, and very decisively, after the 
bile has been boiled for several hours 
with caustic potash — a procedure that 
breaks up the liver-secreted salts, and 
furnishes the derivative, cholate. This is 
doubtless the reason why Pettenkofer's 
test reacts with inspissated, though it 
fails to do so with fresh bile — for the 
taurocholate is readily decomposed by 
boiling only, and the extract is an evapo- 
ration-product ; and, furthermore, why it 



204 T^^ PROPOSED TEST IS [Ch. XII. 

rarely affords at once a distinctive reac- 
tion in jaundiced urines, which are highly 
charged with liver-secreted salts. ^ 

The test for peptones, recently intro- 
duced by Dr. Randolph, of Philadelphia, 
(see p. 90), may likewise be employed for 
the direct testing of bile-salts : and for 
this purpose it is delicate ; but is unfor- 
tunately open to the objection, that 
it reacts equally well with the merest 
trace of peptone — a constituent often 
present in small quantity in the urine of 
hepatic cases, and moreover, generally in 
such traces as to be detected with 
difficulty, and, therefore, cannot always 
be definitely excluded. 

The proposed test is founded on a 
Fliysiolog-ical Meaction*— The test I 
employ, for the direct detection of the 
bile-salts in the urine, is a purely physio- 
logical one : for, it is based on a reaction 

1 Just lately I met with an instructive instance, of this 
fact in a specimen of colourless bile extracted by aspiration 
from the gall-bladder of a jaundiced patient. I first of all 
determined the presence of a fairly large quantity of bile-salts. 
Pettenkofer's test, however, afforded no reaction within 
several hours ; but, after boiling a portion of the colourless 
fluid with liq. potassae, the test furnished the characteristic 
colour change in a few minutes. 



Ch XII.l PHYSIOLOGICAL. 205 

which belongs to the bile itself as it flows 
into the intestines. When the products 
of gastric digestion — peptone and para- 
peptone — which leave the stomach in a 
state of acid solution, meet with the bile, 
they are precipitated, as a tenacioHS 
layer, all over the villi of the lining mem- 
brane of the duodenum. 

A solution of tlie Bile-salts pre- 
cipitates Acidulated Album iuous 
Urine, or Urine cliarg^ed w^tli Pep- 
tone.— The same physiological fact is 
illustrated, outside the body, by acidu- 
lating — by means of citric or acetic acid 
— albuminous urine, ^ or urine charged 
with peptone, and treating it with a 
solution of the bile-salts — or by ox-bile 
freed from pigment, mucin, and fat ; when 
the proteid is swept out of solution. This 
precipitation of albuminous matter from 



1 Physiological writers assert that the bile only precipi- 
tates the proteid froni the acid solution that enters the 
duodenum, when in the form of peptone and parapeptone ; 
and not when in that of albumin — as when albumin is dis- 
solved by an acid. If this be so in the duodenum, it certainly 
is not so in the urine. When a solution of bile-salts is added 
to an acidified albuminous urine, the proteid is precipitated, 
just as in the case of acidulated normal urine artificially 
charged with peptone. 



2o6 A PROTEID TEST [Ch. XII. 

an acid solution is induced, not only by 
the bile-salts — taurocholate and glyco- 
cholate — but also by their derivative — 
cholate of sodium.^ 

Why not employ an Acidulated 
Solution of a Proteid in order to 
detect tlie presence of Bile-salts, or 
the derivative of them, in the urine I 
Hence, as this reaction is a thorough- 
going and decisive one, why not utilize it 
as a means of discovering the colourless 
bile-derivatives that may overflow into 
the urine ? For, if these biliary con- 
stituents are present, in however small 
a quantity, they will surely precipitate an 
acidified solution of a proteid — resembling 

1 There are several conditions that prevent the reaction 
between the bile-salts and an acidified solution of albumin or 
peptone: viz., {a) an insufficiency or an excess of acid; (6) 
the proteid in large quantity ; and (c) the bile salts deficient 
or in great excess. The precipitate with the solmion of albu- 
min or peptone, or with urine containing either proteid, 
dissolves on adding acetic acid, or a citric test-paper to 6om. 
These facts appear to me to be interesting in connection with 
the temporary albuminuria or peptonuria which is confined 
to the digestive periods, and with the increased elimination 
of albumin in chronic renal disease which takes place after 
meals. May not a sub-acid or a per-acid chyme, or an excess 
of the ingested proteid, or a deficient or excessive bile-flow, 
prevent the biliary salts from precipitating — or rather from 
completely precipitating as in health — the albuminoid mate- 
rials which flow into the duodenum, aud thus permit the 
premature absorption of them ? 



Ch.XII.] WITH ACID. 207 

in fact the chyme — when brought into 
contact with the urine. Experiment and 
clinical observation have proved such to 
be the fact. 

Acidification is a necessary condi- 
tion of tlie reaction. — A solution of 
the bile-salts mixes with albuminous urine 
without precipitating the albumin^ : but 
on adding a drop or two of acetic acid or 
a citric test-paper to the mixture, the 
albumin falls out of solution. Then again, 
if the observer takes equal parts of an 
albuminous and of a jaundiced urine, and 
adds a citric test-paper to 6onx of the 
clear mixed urines, he will observe, in the 
course of a minute or so, a cloud of pre- 
cipitated albumin collect in the lower part 
of the tube. In this case the bile-salts 
present in the jaundiced urine precipitate 
the albumin — as in the preceding observa- 
tion : the citric acid merely performing 
the same duty as when employed in the 

iWhen the bile-salt solution is run upon an albuminous 
urine, or more especially upon a normal urine charged with 
peptone, but in neither case acidulated, a delicate zone of 
precipitated proteid appears ; which, however, vanishes on 
mixing up the solution with the subjacent urine: but the opacity 
is restored by a citric test-paper, or by a drop of acetic aci4, 



2o8 ACIDIFICATION NECESSARY. [Ch. XII. 

mercuric or ferrocyanic test for albumin. 
About twelve months ago I encountered 
a fact in urine-testing, which at that time 
I could not explain, nor could I derive 
light either from books or from my 
friends : the same patient, on different 
days, provided me with various samples 
of albuminous urine, which were divisible 
by the action of citric or acetic acid, into 
two classes — one set precipitating freely 
with the acid, the precipitate insoluble 
with heat, and the filtrate albumin-free ; 
and the other set unaffected by the vege- 
table acid. I carbolized a good example 
of each kind, and set it aside — believing 
that the explanation would be forthcoming 
some day or other. On now re-examining 
these specimens, I find, the one that pre- 
cipitates albumin by the organic acid, 
contains a large quantity of bile-salts ; 
while the other has none — or merely a 
little more than the trace that belongs to 
normal urine. ^ The precipitant of the 

1 This patient also on several occasions furnished me with 
specimens containing peptones in the place of most of the 
albmnin. One of these I also carbolized : on re-testing it, I 
^nd the peptones still present, with a trace of albumin; and 



Ch.XII.] PEPTONE TEST SOLUTION. 209 

albumin was, therefore, in this case also, 
the bile-salts, which remained inopera- 
tive, until the vegetable acid was added. 

I have lately met with several urines of 
normal reaction, containing albumin and 
bile-salts, in which the proteid was preci- 
pitated by merely adding an organic acid. 

Acidified Albuminous Urine is a 
test for Bile-saits in tiie Urine.— 
When albuminous urine, acidified by 
acetic or citric acid, is diluted, and run 
upon jaundiced urine, it will show the 
presence of bile-salts : for, along the plane 
of contact of the urines, a sharply-defined 
white band or zone of precipitated albu- 
min will instantly appear — a reaction 
which is indeed very striking and decisive. 

The Peptone test Solution.— Having 
got out the fact, that bile-salts when 
present in the urine precipitate a proteid 
from an acid solution, it was an easy 
matter to discover how to apply it as a 
practical test. On substituting for the 
acidified albuminous urine an acidulated 

on running over it a diluted solution of acetic acid, there 
instantly appears a beautiful thick pearly-white zone. Bile- 
salts are present in large quantity. 



2IO THE PEPTONE TEST. [Ch. XII. 

antiseptic solution of peptone, I obtained 
a test solution much better in all respects 
— being readier and more delicate, and 
withal a preparation devoid of all objec- 
tionable qualities.^ 

Tlie Reaction.— When 2onx of urine, 
containing bile-salts in pathological quan- 
tity, are run into 6oiix of the test solution, 
an opalescence appears proportionate to 
the amount of the bile-derivative. It dif- 
fers from all other urinary precipitates 
induced by an acidified reagent, in dis- 
solving up completely on adding a drop 
or two of acetic acid, or a citric test- 
paper ;2 and in diminishing, but not disap- 
pearing, on boiling. 3 

1 The following is the formula for the solution : 

Pulverized peptone (Savory and Moore) gr. xxx. 
Salicylic acid, gr. iv. 
Acid acetic (B.P.) Utxxx. 
Distilled water to 58. 
Perfect transparency is obtained after repeated filtration. 

2 When, after dropping in the test-paper, the tube is set 
aside for a minute or two without shaking, the observer will 
find the portion below quite transparent, and that above still 
opaque : and, on shaking up the contents, he will disperse the 
opalescence throughout. 

3 When the test solution is precipitated by bile-salts, the 
precipitate has the same peculiarities : dissolving when further 
acidified, and lessening — certainly not vanishing — when 
boiled. 



Ch. XII.] THE RE A CTION. 2 1 1 

The opacity is not affected by such 
warmth as suffices for the solution of 
urates, or even by a higher temperature 
than this impHes. 

When the test solution is run upon 
urines containing an excess of bile-salts, 
an immediate and very distinctive reaction 
takes place where the fluids meet — 
namely, a sharply defined white band of 
precipitated peptone : and, on oscillating 
the tube, so as to mix up a little of the 
urine with the test solution, the upper 
part of the column presents an opacity — 
the density of which is proportionate to 
the amount of the bile-derivative present 
— in marked contrast with the trans- 
parency of the urine below. On 
further agitation, a limit is reached 
when the opalescence diminishes, and 
perhaps, finally vanishes : then it is 
restored, on adding more of the test 
solution. 

Delicacy of tlie Test: Objections.— 
The test is undoubtedly a very delicate 
one : for, I have readily determined by 
it the presence of i part of bile-salts in, at 



^12 THE PEPTONE TEST. [Ch.Xil. 

least, from 18,000 to 20,000 parts of a 
solution of chloride of sodium. 

The question will naturally be asked : 
is there anything, besides bile-salts, in the 
urine that will react in like manner with 
an acidified solution of peptone ? So far 
I have failed to put my finger on any such 
constituent : and I have tried several — 
among them kreatin, kreatinin, leucin, 
tyrosin, hippuric acid, and fatty acids 
(monatomic and diatomic).^ 

Besides this failure to discover in the 
urine a non-biliary substance that can 
precipitate the peptone, all the positive 
evidence hitherto obtained undoubtedly 
supports the position, that it is a liver- 
derived product present in the urine, 
which reacts with the test. The testimony 
of the facts is cogent in this direction. 

1 It is well known that a concentrated solution of chloride 
of sodium in the presence of an acid will precipitate a 
proteid. When the chlorides of the urine appear in excess, 
will they react with the test solution ? Experiment shows, 
that when the peptone solution is run upon a solution of salt 
of any specific gravity less than 1050, no precipitation what- 
ever appears. Therefore, the urinary chlorides are not a 
source of error: and more especially, when it is called to 
mind, that a condition of the testing is the reduction of all 
urines to the uniform specific gravity of 1008. 



Ch.XlI.] THE PEPTONE TEST. 213 

{a) The biliary salts extracted from the 
bile 'produce an identical reaction. 

(h) The liver is the sole organ that 
furnishes a secretion which precipitates 
a proteid from an acid solution. All the 
secretions, except bile, either do not act 
on the proteids at all — such as saliva — 
or they dissolve them — such as the 
gastric and pancreatic juices. And, 
furthermore, the biliary salts are the 
only constituents of the bile that possess 
the property of throwing a proteid out of 
solution. 

[c) The test demonstrates, that the 
proportion of the bile-salt present in 
normal urine varies in a well-defined 
manner with the activity of the digestive 
organs (see p. 225). This clearly shows 
that the substance that reacts with the 
test is intimately connected with the 
digestive process. 

{d) Clinical experience. (See Ch. xiii.) 

I have checked mucin and urates — the 
fallacies to which all acid urinary tests 
are liable. 

Mucin, — I have already pointed out 



:2l4 THE PEPTONE TEST, [Ch. Xll. 

that mucin in acid solution is not pre- 
cipitated by the addition of further acid 
(see p. no). So that when this con- 
stituent is thrown down in urine of acid 
reaction, it seems highly probable that 
the acid added is not the reagent, but 
merely supplies the requisite degree of 
acidity to enable the precipitant already 
present to operate — as in the case of the 
bile-salts and albumin (p. 207). If so, a 
mucin precipitate merely indicates the 
presence of bile-salts. Furthermore, on 
running the test solution on the muci- 
parous mixture of normal urine and clear 
saliva, the reaction is rather diminished 
than intensified. Then again, the methods 
of observation, requiring a uniform low 
specific gravity, obviate a liability to 
error from this cause (p. 215). 

Urates. — Inasmuch as the modes of 
testing — both qualitative and quantitative 
— require the uniform dilution of the 
urines to the specific gravity of 1008, a 
condition is provided which secures the 
solution rather than the deposition of 
urates : so that all observations may be 



Ch.XlL] THE MODE OF TESTING. 215 

trusted, without the necessity of resorting 
to warmth as a corrective. 
The mode of preliminary testing.— 

In every case the urine to be tested must 
be quite clear. If turbid from urates, it 
should be clarified by warmth : if from 
phosphates, very small pieces of citric 
test-paper should be added and skaken 
up with the urine, until it becomes trans- 
parent — special care being taken not to 
acidify beyond this limit. It is, upon the 
whole, best to filter turbid urines : and 
this proceeding is necessary if the cause 
of the opacity is organic, or doubtful. 
When the urine is cloudy from blood, 
it should first be boiled,^ and then filtered 
— for filtering alone does not clarify it. 

The specific gravity of the urine is to 
be reduced to 1008 (p. 48). The object 
of this direction is to obviate fallacious 
inferences apt to be drawn from reactions 
with urines of varying densities — concen- 
trated urines often reacting as if there 

1 Boiling the urine does not destroy the bile-salts. It is 
true, if any taurocholate of sodium is present, it is broken 
up : the products being taurin and cholate of sodium. But 
the peptone test reacts with the cholate as well as with the 
liver-secreted salt. 



2i6 THE PEPTONE TEST. [ch. Xil. 

were present an excess of bile-salts : and 
urines of low specific gravity, though 
sometimes affording a reaction similar 
to that of normal samples, actually con- 
taining an increased proportion. 

Twenty minims of urine are added to 
6onx of the solution. 

If the bile-salts are present in excess a 
distinct milkiness appears, which develops 
somewhat further in the course of a 
minute or so : and the depth of the 
opacity is proportionate to the amount 
of the bile-derivatives. 

If the urine contains the average pro- 
portion found in the majority of healthy 
urines — or, of course, less than that pro- 
portion — the reaction is a mere tinge of 
milkiness, and is, moreover, not immediate. 

The ^contact method.'' When the test solu- 
tion is gently run over a urine (reduced to 
the sp. gr. of 1008) containing bile-salts 
in pathological amount, an immediate re- 
action takes place (see p. 211) : but when 
the quantity is normal or sub-normal, the 
reaction is not instantaneous — it gradually 
appears in the course of a minute as a 



Ch.Xli.] QUANTITATIVE ESTIMATION. 217 

delicate thread - like line, which may 
undergo a little further development 
during the lapse of a few minutes. 

Qitantitative estiisiation. — Clinical 
observation demands something more 
definitely comparable than can be de- 
rived from the mere qualitative testing : 
for, it should decide as accurately as 
possible the quantitative variations of 
the urinary elimination of the bile-salts 
observable in different pathological con- 
ditions, in the various stages of disease, 
and in the effecfts of treatment. I have, 
therefore, devised the following procedure 
to meet this requirement. 

The only additional apparatus required 
is a permanent standard of opacity (see ch. 
xiv.), to represent the average discharge of 
bile-salts in healthy urine. The opacity is 
that provided by mixing together, in equal 
proportion (60 nx), the urine — reduced to 
the sp. gr. of 1008 — and the test solution. 

To 6orrt of the test solution, the urine 
of sp. gr. 1008, is added — in ordinary 
cases lourt or 2oiTt at a time, and allow- 
ing a minute to elapse after each addition 



2i8 QUANTITATIVE ESTIMATION. [Ch. Xli. 

— until the opacity induced is seen to be 
exactly equal to, or to slightly over-step, 
that of the standard — the tubes being 
held to the light, shaded by a dark back- 
ground, such as that of the coat-sleeve. 

If 5oiTt or 6orrL of the urine bring up 
the opacity merely to that of the standard, 
the proportion of bile-salts is not outside 
the normal range — in the direction of 
increase. But an}^ smaller quantity of 
urine required indicates an excess of the 
biliary derivatives over the physiological 
variations. The smaller the amount of 
urine needed, the larger the proportion of 
bile-salts present — according to the fol- 



lowing table : — 

Urine. 
Minims. 


Drops. 


Percentage increase of bile- 
salts over the normal 
standard. 


I 


or 


2 


= 


6,000 


2 


,, 


4 


= 


3,000 


3 


,, 


6 


= 


2,000 


4 


,, 


8 


= 


T.500 . 


5 


,, 


10 


= 


1,200 


lO 


,, 


20 


= 


600 


15 


,, 


30 


= 


400 


20 


M 


40 


= 


300 


25 


,, 


50 


= 


240 


30 


,, 


60 


= 


100 


35 
40 


" 


70 
80 


= 


83 

66 


45 


11 


90 


=s 


50 



Ch.Xll.] PEPTONE TEST-PAPER. 219 

Charges of bile-salts beyond 700 per 
cent, increase over the normal average 
amount, are only met with now and then : 
but they may be encountered in isolated 
samples of even non-jaundiced urine ; as 
in a specimen I lately examined contain- 
ing 1,500 per cent, increase of biliary salts, 
but quite free from bile-pigment.^ 

The Peptone Test-paper.— In accord 
with the purpose of this little book, I 
have arranged the peptone test in the 
form of test-paper, so as to serve the 
convenience of observers in the prelimi- 
nary testing. The test-paper is perma- 
nent and reliable, and is best used in the 
following manner: — 

The peptone test-paper along with 
half a citric paper is dropped into 50iTt or 
Gorrt of water in the larger test tube or a 
wine glass : after the lapse of a minute or 
so the solution is slightly agitated, and, 
on being set aside for another minute,^ is 
ready for use. 

1 Pettenkofer's test afforded at once a beautiful reaction 
with this sample. 

2 The solution thus left at rest for a short time becomes 
quite transparent, 



220 PEPTONE TEST-PAPER. [Ch. XII. 

The solution thus prepared is taken up 
by the pipette, and carefully run over the 
transparent urine : when if bile- salts are 
present in larger amount than the normal 
average, an immediate reaction is ob- 
served, as a pearly-white thread or 
band ; but, with urine devoid of this 
excess, a delicate zone may appear, but 
only in the course of from one to two 
minutes. 

The test may likewise be employed 
equally well in the following ready way : 

The test-paper along with half a citric 
paper is dropped into 6ora of water : and 
2oiri of urine, reduced to the sp. gr. of 
1008, are added. The contents of the 
tube are oscillated for half-a-minute, and 
then set aside for a minute — so as to 
allow time for the clearing away of 
gaseous particles and the development of 
the reaction. If bile-salts are present in 
excess a distinct milkiness is apparent : 
but if in normal or sub-normal amount, 
there is only a slight haze, or no obvious 
change, 



CHAPTER XIIL 



CHOLURIA: 
THE CLINICAL SIGNIFICANCE OF BILE- 
DERIVATIVES IN THE URINE. 



A mere sketch admissible. — As in 

the case of albuminuria and gl^^cosuria, 
so in this, I can but provide in this Httle 
work merely an outline of the clinical 
bearings of the biliary derivatives in the 
urine, and leave each observer to fill in 
the sketch with the pencil of his own 
experience. 

The Bile-coloiii'ed Urines of Jaun- 
dice represent but a portion of the 
Urines charged w ith Biliary Deriva- 
tives.— According to my observations 
jaundiced urine is but a section of the 
large group of urines containing biliary 
matter in pathological proportions. 
Hence, I venture to coin the term 
' choluria ' in order to tersely indicate the 

Q 



222 THE BILE PIGMENT. [Ch.XIII. 

presence of bile-elements — the colourless 
ones in particular — in abnormal quantity 
in the urine. 

I. The Bile-Pigment. 

The presence of the biliary colouring 
matter in the urine characterizes jaundice 
from whatever cause. 

Apart, however, from jaundice — as 
ordinarily recognized — bile-pigment in 
small quantity may temporarily appear in 
the urine : as in the acute disturbance of 
the liver that belongs to bilious attacks ; 
but, whenever this is the case, a diminu- 
tive form of jaundice may be said to exist, 
which, were the biliary embarrassment 
to continue long enough, would declare 
itself in the ordinary symptoms. 

An excess of the colourless bile- 
derivatives always accompanies 
biliary pig^ment in the urine. — So 
far as my observations have extended, 
whenever I have met with bile-pigment in 
the urine, the peptone test has invariably 
demonstrated the presence of the biliary 
salts in large quantity (see p. 234), Hence, 



Ch. XIII.] THE BILE SALTS. 223 

provisionally, I am led to regard the term 
* jaundiced urine' as synon^^mous with 
that of ' pigmentous choluria.' 

II. The Bile-Salts. 

The Physiological Variations of the Renal 
Elimination of Bile- Salts, 

Bile-ISaltis in liealtliy urine indi- 
cated toy the Peptone Test. — Some 
few years ago that sagacious observer, 
the late Dr. Murchison, remarked that 
*' not only in jaundice, but in health, a 
portion of the bile pigment, as well as of 
the bile acids, formed in the liver, is 
absorbed into the blood": if so, may we 
not expect to find a small quantity of the 
central components of the bile (the biliary 
salts), or a derivative of them, in healthy 
urine ? — providing, of course, they are 
not . completely broken up by chemical 
action,^ and the mode of direct testing 
is sufficiently delicate for the purpose of 
detection. When it is remembered, that 



1 Frerichs as well as Murchison believed that the bile- 
acids normally absorbed into the blood from the liver were 
metamorphosed by oxidation into other products. 



224 PHYSIOLOGICAL ASPECTS [Ch.Xiil. 

in man the liver secretes on an aver- 
age each day not less than 4 ounces^ of 
bile-salts, it will surely not be surprising, 
if a fraction — as it were — of this large 
quantity should, under the ordinary con- 
ditions of health, get adrift from the portal 
into the general circulation, and be dis- 
charged by the kidneys : in fact, were the 
amount of these leading biliary constitu- 
ents but half that just indicated, the non- 
appearance of a small portion of it in the 
urine would, I think, be regarded by 
most physiologists as improbable — being 
contrary to anticipation suggested by kin- 
dred data. Certainly so far the biliary 
salts of the blood have not been isolated : 
but their absence cannot be inferred 
from this negative evidence, for the 
quantity is doubtless too small for sep- 
aration and detection by the methods 
hitherto employed. It is not so, however, 
with the urine : for the bile-acids have 
been separated by Naunyn and Draggen- 
dorf in healthy non-jaundiced urines ; and 

1 According to Bidder and Schmidt the daily bile-flow of a 
man, weighing 140 lbs., is about 50 oz. ; and the charge of 
bile-salts over 9 per cent,, or a little over 4 oz. 



Ch.XIIL] OF THE BILE SALTS. 225 

lately Lepine and Guerin have shown that 
the greater part of that portion of the un- 
oxydized sulphur present in the urine 
which is oxydized with difficulty by re- 
agents, is derived from the bile, by the 
re-absorption of taurocholic acid.^ Then 
again, it has been demonstrated that tau- 
rin — derived from taurocholic acid — is 
eliminated in small quantity by the healthy 
kidney. I, therefore, conclude that the 
diminutive reaction of the peptone test 
solution with normal urines accords with 
the presence of a trace of bile-salts dis- 
covered in them by physiological chemists : 
and from several observations I am dis- 
posed to estimate the average amount as 
about I part in from 10,000 to 15,000. 

The amount of Bile-§alts present 
in ttie noranal urine of the same 
individual varies at different periods 
throug^hout the twenty-four hours : 
the causes of variation.— A large num- 
ber of observations on the urine of healthy 
persons with the peptone solution has 
demonstrated the fact, that the colourless 

1 See the Lancet, vol. i., 1885, p* 307. 



226 PHYSIOLOGICAL ASPECTS Cch. XIII. 

biliary derivatives are discharged by the 
kidneys in varying proportions at different 
times in the course of the day. Though 
always present, they are increased at 
certain periods and diminished at others : 
and I find this variation definitely hinges 
on the digestive act. 

The diagrams on the opposite page 
represent hourly estimations of the bile- 
salts in the urine of a healthy adult, aged 
44, on two consecutive days : when every 
sample of urine was reduced to the uni- 
form specific gravity of 1008 ; and the 
degrees of opacity, induced by mixing 
6orrt of the diluted urine with the same 
quantity of the test solution, were regis- 
tered according to a determined scale 
represented by the figures i, f , |-, J, -J. 
The reader will observe that the maxi- 
mum amounts appear during the periods 
of fasting — as in the urine passed in the 
morning and before meals ; and that the 
proportion falls quickly — generally in an 
hour — after each meal, and attains its 
minimum in from three to four hours. 

It would, therefore, appear that the 



The hourly elimmatipn of Bile-salts tythe Unne: 
shewing the effects of digestion and exercise. 




Ch.XIIL] OF THE BILE SALTS. 229 

renal elimination of the biliar}^ salts is 
the converse of the bile-flow into the 
duodenum : for, according to the facts 
provided b}^ biliary fistulae established 
in the dog, the discharge of bile into the 
bowel rises rapidl}^ immediately after eat- 
ing, reaches its maximum in from two to 
six hours, and returns to its minimum by 
the time of the next meal ; but never 
ceases — even though fasting is prolonged. 
According to my observations this cen- 
tral fact is modified by various hygienic 
conditions : among which exercise is the 
most powerful. On comparing the dia- 
grams — one representing the subject 
walking only two miles, and the other 
ten miles — the reader will note, that when 
the exercise was insufficient, the waves of 
increased elimination before dinner and 
the evening meal were imperfectly de- 
veloped — attaining to merely the half 
standard opacity ; and that, when the 
walking was extended to ten miles, the 
renal discharge of the biliary salts follow- 
ing the digestive fall reached the highest 
degree. It is pretty clear that moderate 



2^0 PHYSIOLOGICAL ASPECTS [Ch. xiil- 

exercise invigorates the digestive process : 
for, with a fair amount of walking between 
meals, the withdrawal of the bile-salts 
from, as well as the return of them to the 
urine, is rendered more decisive and 
speedy than when a lounging life is led. 
Indolence, therefore, either favours the 
retention of these colourless excreta within 
the systemic blood (cholsemia), or causes 
them to linger within the limits of the 
portal circulation, and prolongs each di- 
gestive effort. 

The systemic overflow of the biliary 
salts is probably influenced by other hy- 
gienic conditions : such as meteorological 
changes of temperature and of atmos- 
pheric pressure ; the nature of the diet ; 
and alcohol. Though I have not yet 
studied with sufficient care the effects of 
alcohol on the renal elimination of these 
elements, I think I am justified by the 
few data observed, in expressing the belief, 
that in the first instance, it is a checking 
agent, and then — after inducing conges- 
tion of the liver — it brings about an in- 
creased discharge, which may be even 



Ch.XlIL] OF THE BILE SALTS. 231 

detected during the periods of digestion 
— when ordinarily the renal overflow of 
the biliary excreta is at its minimum. 
Should these positions be confirmed by 
further observation, it would seem as if 
alcohol should be classed with indolence 
as a cause of cholaemia and congestion of 
the portal system : and is, therefore, the 
opposite of exercise. 

The reader should be reminded that the 
urine of patients does not present such 
great variations in the amount of bile- 
salts as are indicated by the diagrams 
constructed from hourly observations: for, 
as a rule, it is allowed to collect in the 
bladder for several hours together, and 
thus acquires a more uniform charge. 
When, however, the bladder is cleared 
just before a meal, the urine voided two 
or three hours afterwards will in health 
show the digestive withdrawal of the 
biliary salts. In order to judge of the 
renal elimination of these constituents the 
observer should select the urine of fasting 
— before breakfast — and of digestion — two 
hours after breakfast : or he should obtain 



^3^ CLINICAL ASPECTS rch.Xill. 

a sample of the whole twenty-four hours' 
discharge. 

The clinical significance of the renal excretion 
of biliary salts. 

Data provided by experiments on 
animals.— A review of the facts furnished 
by the injection of the bile-salts into the 
blood of animals (mainly dogs) forms a 
fitting introduction to the study of the 
clinical aspects of the renal excretion of 
these colourless biliary derivatives. 

The following symptoms and structural 
changes have been recorded by several 
observers (Feltz, Ritter, Rohrig, Albers, 
and others.) 

(a) Pulse and respiration retarded. 

(b) Arterial tension and temperature 
lowered. 

(c) Food refused, and loss of flesh rapid. 
Vomiting of bile and blood. 

(d) Diarrhaea: bilious, sometimes bloody. 

(e) Haemolytic changes, capillaries ob- 
structed and haemorrhages. The blood 
more fluid than normal, and less coagul- 
able. The red discs dissolved, and the 
serum red-coloured from liberated haemo- 



Ch.XIII.] OF THE BILE-SALTS. 233 

globin,^ and milky from fat. The passage 
of the blood obstructed in the capillaries : 
the red discs flow together en masse, 

(/) Parenchymatous degeneration of 
glands, muscles, liver, kidneys, &c. 

(g) Tetanic convulsions, followed by 
coma and death. 

(h) Urine albuminous, and red from 
dissolved haemoglobin. 

The symptoms and tissue changes vary 
with the amount of bile - salts injected : 
thus, it is always needful to administer 
large repeated doses in order to induce con- 
vulsions, coma, and death ; but a small 
quantity will produce the analogue of a 
bilious attack, when there is merely 
observed — retardation of pulse and respi- 
ration, lowering of arterial tension, refusal 
of food, vomiting, and perhaps diarrhaea. 

The balance between production 
and elimination.— The biliary products 
discharged into the bowels are mainly 
utilized in digestive work : and a certain 
comparatively small portion of them must 



1 When a solution of the bile-salts is added to a drop of 
blood under the microscope the corpuscles rapidly disappear. 



234 ^^^ BILE-SALTS [Ch. XIII 

pass out with the faeces — or good health 
is out of question : unless, perhaps, the 
renal elimination can in some degree 
compensate for the intestinal failure. As 
a rule, however, when either of these 
channels, by which biliary matter is 
normally excreted, is obstructed — and 
above all when both are embarrassed or 
blocked — the blood becomes surcharged 
with the poisonous excreta (cholaemia), 
and then the experiments on animals 
become living facts in our clinical 
experience : the form of blood-poisoning 
being acute or chronic, mild or severe, or 
individualized by idiosyncrasy of tissue, 
or by some special concomitant condition, 
such as fever and the like. 

When, therefore, the balance — which 
subsists in health — between the produce 
tion of these poisonous products and 
their elimination is disturbed, disorder or 
disease is induced : as surely as the smoky 
atmosphere of a room is the natural con- 
sequence of a narrowed or obstructed 
chimney. 

The clinical observation of the bile- 



Ch. XIII.] IN J A UNDICE, 235 

salts in the urine resolves itself into the 

detection of an excess and of a check to 

elimination, or of an insufficient discharge. 

The Bile-salts are increased.— My 

clinical experience has demonstrated an 
excess of biliary salts in the urine in the 
following morbid conditions : — 

I. Jaundice. — Authorities are divided on 
the question of bile-salts in the urine of 
jaundice : some (such as Frerichs, Stad- 
ler, Murchison) holding that they are 
invariably absent — believing that they 
are decomposed by the blood ; others 
(Kiihne) always detecting them — what- 
ever the form and the duration of the 
jaundice ; and others (Geo. Harley) as- 
serting the presence of them in all cases 
of obstructive jaundice — while, in fact, 
bile is being secreted by the liver and 
absorbed into the blood — but failing to 
discover them when the liver, from disor- 
ganization, ceases to secrete bile. All 
this diversity of opinion must, I think, be 
referred either to the defectiveness of the 
processes employed for the separation of 
the bile-acids from the urine, or to the 



236 THE BILE-SALTS [Ch. XIII. 

want of a clinical test of sufficient ac- 
curacy and delicacy. So far my exper- 
ience agrees with that of Kiihne : for I 
have invariably found an increase — and 
generally a very decided increase — of the 
bile-salts in all forms and stages of jaun- 
dice ; this even in cases of from one to 
four years' duration. According to my ex- 
perience of jaundice, the bile-salts are not 
only apt to appear in the urine in increased 
quantity before the appearance of bile-pig- 
ment, but to persist for some weeks after 
the urine has become quite free from it. 

2. Functional disorders of the liver : bilious- 
ness, — The bilious may be broadly divided 
into two classes : namely, those in whom 
the liver is loaded with biliar}^ products, 
either from habitual per-secretion, or from 
an accumulation of them, which is less 
or more constant, or is only occasional ; 
and those in whom the secretion of bile is 
always below the average — sub-secretion. 

Acute biliousness. — Those who always 
^ make ' bile, as well as those who suffer 
from biliary engorgement due to defective 
excretion, &c., are prone to 'hepatic 



Ch. XIII. IN ACUTE BILIOUSNESS. 237 

storms ' or periodical overflows of bile 
either into the bowels or the blood, or 
into both : as when there occurs a sudden 
alteration of arterial tension — as a rise 
from excitement, or a fall from chilling or 
other meteorological influence — or when 
a dietetic error is committed. Then, when 
the bile-derivatives are absorbed in excess 
into the blood — as they generally are 
— the symptoms resemble those of acute 
poisoning by small doses of the bile-salts 
in animals : namely, feeble pulse, palor, 
coldness of the extremities, and a feeling 
of chilliness throughout, from imperfect 
filling of the arterioles; slow sometimes 
gasping breathing ; nausea and vomiting ; 
and occasionally diarrhaea. In migraine 
these symptoms, which characterize the 
ordinary forms of acute poisoning by the 
bile-salts, are overshadowed by the painful 
disturbances of the fifth and of the optic 
nerves : neurotic effects which may spring 
from the same central cause ; but in these 
cases the attack is probably preceded or 
accompanied by an arrest or a diminution 
of the renal elimination of the biliary salts, 



238 THE BILE-SALTS IN [Ch. XIII. 

followed by an augmented discharge which 
affords immediate relief. In an ordin- 
ary attack of acute biliousness the bile- 
salts flush the blood, and are eliminated in 
increased quantit}^ and more particularly 
so towards the close of the disturbance. 

Acute bile-acid poisoning may, however, 
go beyond the stage implied by the ordin- 
ar}^ bilious attack : it ma}' even become so 
intense as to induce convulsions — which, 
however, as a rule, subside as the suddenly 
induced excess of the colourless bile-pro- 
duct in the blood is cleared awa}^ either 
by the kidneys, or by the bowels, or by 
the skin ; such a severe disturbance is 
apt to follow an excessive indulgence in 
alcohol, or the taking of some indigestible 
article of diet, or of too large a meal. 

Chro7iic hilmisness is also a cause of an 
increased systemic diffusion of bile-salts, 
and the excessive renal elimination of them. 
Then the disorder is, as a rule, not purely 
. functional : but depends on hepatic conges- 
tion induced by alcohol — the initial stage 
of cirrhosis ; by too good living ; or by some 
obstruction to the portal circulation, as 



Ch.XIII.] CHRONIC BILIOUSNESS. 239 

in heart disease ; or by the congestive 
effects of malaria on the Hver and spleen. 
Cases of chronic biliousness are, however, 
now and then met with which, though 
providing an excess of bile-salts in the 
urine, do not exhibit the ordinary signs of 
hepatic congestion, and are not referrible 
to the causes just indicated. But chronic 
biliousness in the majority of cases arises 
either from sub-secretion of bile, or the re- 
tention of biliary elements in the blood 
(see p. 247-9). When constipation is a 
prominent feature in a case of biliousness, 
as it frequently is, the bile-salts will be 
detected in greater excess than when the 
bowels are regular or free : and this is not 
surprising — for constipation means reten- 
tion of bile about the portal s\^stem ; favour- 
ing, as it does, a retarded flow in the bile- 
ducts, and absorption of chelate of sodium 
contained in the contents of the small 
intestines and in the faeces.^ In any case 



1 1 have, however, every now and then discovered a decided 
excess of bile-salts in the urine in cases of biliousness with 
free alvine evacuations — these being quite loose and bright 
yellow : as if the biliary elements overflowed into the blood 
as well as into the bowels. 



^40 BILE-SALTS IN DISEASES [Ch. XIIl. 

of hepatic disturbance, whenever the edge 
of the hver is to be felt below the margin 
of the thorax, and is sensitive to the 
touch ; or when, without obvious enlarge- 
ment of the liver, the fingers pressed well 
under the low^er right ribs,- elicit tender- 
ness, bile-salts in excess will, in all proba- 
bility, be discovered in the urine. But 
on the other hand, these constituents are 
frequently found in excess without there 
being any tenderness of the liver. 

In chronic biliary derangement I have 
frequently found the bile-salts in greater 
excess in the urine voided during the 
period of digestion than in that discharged 
before meals : e.g. two hours after break- 
fast than on rising. 

The urine of hepatic embarrassment, 
producing acute and chronic biliousness, 
is that of sub-jaundice : a minimal form 
of jaundice, which, like the major form, 
is characterized by a surcharge of bile- 
derivatives in the blood, and the elimina- 
tion of them by the kidneys ; but differs 
from ordinary jaundice, in furnishing 
urine which not only contains a smaller 



Ch. XIII.] OF LIVER AND SPLEEN. 241 

proportion of bile-elements, but always 
presents an excess of the biliary salts, 
while it is only occasionally pigmentous. 

3 . Diseases of the liver — apart from jaundice, 
I have found an excess of bile-salts in the 
urine of carcinoma ; amyloid disease ; 
enlargement of the liver generally ; cirr- 
hosis ; and in that of tumours probably 
hepatic. 

4. — Diseases of the spleen. In several cases 
of choluria the liver was enlarged as well 
as the spleen : but in others the enlarge- 
ment was confined entirely — or almost 
entirely — to the spleen ; but, notwith- 
standing- the absence of definite hepatic 
disease, the bile -salts appeared in the 
urine of these cases in large excess, 
with a little albumin, and they were 
not accompanied by bile-pigment. This 
clinical fact appears to me of noteworthy 
significance in connection with the distri- 
bution of the biliary salts in the viscera : 
in supporting, in fact, the conclusion to 
which I am led by experimental data — 
namely, that these elements appear 
in large quantity in the splenic pulp ; 



^42 BtLE-SALTS IN PEVEH. [Ch. XIII. 

indeed the majority of my observations 
suggested a larger proportion of them 
there than in the parenchyma of the Hver. 
But this important matter demands 
further enquiry. Should, however, the pro- 
visional position be afterwards affirmed, 
it must throw^ light on the haemolytic 
function of the spleen.^ 

5. Fever, — A rise of temperature from 
whatever cause always induces a systemic 
excess of bile-salts. With a temperature 
of 104"^, and without any suspicion of 
liver affection, I have known the renal 
elimination to exceed 400 per cent, increase 
over the normal standard. Even a slight 
rise — such as that of 1° or 2° — increases 
the renal discharge of these elements. 

6. Hc^molytic diseases. — Dissolution of the 
blood — and especially of red discs— ob- 
struction of the capillaries, and haemorr- 
hages are prominent facts in the poisoning 
of animals by injecting bile-salts into their 



1 For details on this and other points in connection with 
this subject I must refer the reader to my paper ''A contribu 
Hon to the clinical study of the liver viewed through the urine.'' 
The Lancet, vol. L, 1885. 



Ch. XIII.] HEMOLYTIC DISEASES. 243 

veins. On turning to clinical experience 
we find the counterpart of these experi- 
mental data. 

(a) Anemia. — In anaemia the balance, 
which in health is maintained between 
the generation and the destruction of the 
blood corpuscles, is disturbed. There is 
either a failure in the haemogenesis, or an 
increase of the haemolytic process : 
determining, as the case may be, a haemo- 
genic or a haemolytic form of the ailment. 
Probably the defect is generally on the 
side of construction : but I have met with 
several instructive examples of the haemo- 
lytic type, in which there was a consider- 
able excess — pretty regularly and per- 
sistently maintained — of bile-salts in the 
urine ; then it was that some attention to 
the portal organs was indicated, and was 
of greater service than the ferruginous 
treatment of the blood state — the per- 
nicious work of the liver apparently 
causing the failure. 

As yet I have not had opportunities of 
studying, in connection with the bile-salts, 
pernicious ancBmia ; and progressive ancBmia^ 



244 HMMOLYTIC DISEASES. [Ch. Xiil. 

which has a prima facie resemblance to 
the pernicious form. 

In splenic leucocythcBmia I have found 
a large excess of biliary salts in the urine : 
in one case as much as 600 per cent, in- 
crease ; in another over 400 per cent. 

In malarial ancBmia (in cases even that 
did not present recognisable enlargement 
of the liver or spleen, or other organic 
changes) I have found a marked increase. 

In hcBMoglohimma the blood corpuscles 
undergo rapid and wholesale solution : and 
the liberated haemoglobin dialyses into the 
urine (see p. 32). Since I began to use 
the peptone test I have merely examined 
the urine of one case of this interesting 
ailment — interesting specially from the 
pathological relationship which it suggests 
between a suddenly induced hepatic or 
portal disorder, flooding the blood with 
the central component of the bile, and 
the rapid haemolysis : and in this case a 
large excess was indicated — no less than 
1,500 per cent. This observation is cer- 
tainly suggestive : and it will, I think, be 
a matter of some clinical interest to ex- 



Ch.XllL] BILE-SALTS DIMtNlSHED. 245 

amine haemoglobinuric urines from this 
standpoint. Before applying the test the 
observer should always throw down the 
albumin by heat, witho^tt acidifying the urine 
either before or after the boilings and then 
filter. 

(h) Scurvy. In the four cases examined 
there was a large excess. 

Capillary hoemorrhage is also a promi- 
nent feature of the cholaemia of jaundice, 
of leucocythaemia, of diseases of the spleen 
and liver, and of fevers — at the onset 
especially. It is also met with in the 
cirrhotic kidney, which appears to afford 
a check to the renal elimination of the 
bile-salts (see p. 247). 

Tlie urinary elimmatioii of bile- 
salts is insiifiicieiit. — In sketching this 
clinical aspect of the subject I must 
divide the cases into two classes : namely, 
those in which the bile-salts are present 
in great excess in the blood and the 
elimination of them by the kidneys is 
checked or rendered defective ; and 
those in which the production of them 
is not excessive, but the renal dis- 



246 INEFFICIENT EXCRETION [Ch. XIII. 

charge is subnormal. In all there must 
be a persistent and increasing reten- 
tion of these excrementitious matters 
in the blood — perhaps only now and 
then relieved by the vicarious efforts 
of the bowels, or skin, or by an occa- 
sional spurt — as it were — of the 
kidneys. 

The prodttction is increased hut the elimination 
is diminished. — When the systemic blood 
is greatly sur- charged with bile -salts — 
as in fever, jaundice, certain forms of 
anaemia — the patient is, as a rule, safe 
from acute poisoning so long as the 
kidneys discharge them with freedom : 
it is true he suffers all the while from 
the textual degenerations induced by the 
presence of them in excess in the blood ; 
but, while the charge of them is kept down 
below a certain dose — as it were — by effi- 
cient elimination, he runs no risk of immi- 
nent danger. But it is probably otherwise 
when the kidneys fail to bale out the 
pernicious material : for, then, it accumu- 
lates, and effects further destruction of 



Ch.XllL] OF BILE-SALTS. 247 

the cellular elements, and may even reach 
that percentage proportion which experi- 
ment has shown will induce convulsions 
and coma — a catastrophe which may, 
however, be averted for a time by a 
vicarious evacuation from the bowels, or 
the skin, or perhaps by blood-letting. In 
high fever — especially at the onset in 
children — this is by no means an un- 
common event : and it may be that many 
a fever patient has been sacrificed b}^ the 
injudicious checking of a critical or vica- 
rious evacuation. It is likewise now and 
then met with in jaundice : when the pa- 
tient unaccountably becomes apparently 
uraemic, or at any rate he is seized with 
convulsions and dies comatose. 

It is, therefore, of some practical im- 
portance, whenever there is a large pro- 
portion of bile-salts in the blood — as for 
example, in fever and jaundice — to see 
that the renal eliminaton of these noxious 
constituents is sufficiently free : and, when 
a decided falling off takes place, while the 
fever is high, or the jaundice is unabated, 
the observer should be ready to assist 



248 INEFFICIENT EXCRETION ch. XIII.] 

evacuation by other channels, and should 
be on his guard not to check a salutory 
vicarious discharge. 

The prodtiction is not excessive hut the kidneys 
fail to keep pace with it. — I have met with 
several cases, in which the most feasible 
pathological reading was blood-poisoning 
from biliary products ; yet there were no 
grounds for believing the digestive organs 
much at fault. The only definite fact that 
could be made out from an examination 
of the secretions, was a distinct falling off 
in the renal elimination of bile-salts — a 
fact which appeared to provide a clue in 
explanation of the obscure symptoms 
suggestive of a toxaemia : such as a be-" 
clouded listless state of body and mind; 
good-for-nothingness ; melancholy ; hypo- 
chondriasis ; and a sallow complexion, 
probably due rather to the imperfect 
filling of the arterioles — permitting a 
fuller view of the adipose tissue — than to 
biliary pigment. It is true, the patients 
of this type frequently — if not invariably 
— present brown-stained patches on the 
skin: but such pigmentation is probably 



Ch.Xlll.] OF BILE SALTS. 249 

derived from a coloured decomposition - 
product of the biliary salts. Is there a 
mild form of cholaemia referrible to pre- 
mature failure of renal excretory work ? 

After 60 years renal elimination — as a 
whole — falls very decidedly, even becom- 
ing precarious, notwithstanding the lack of 
any evidence of structural mischief of the 
kidneys : and I have known the failure to 
excrete biliary salts become every now 
then apparently such as to suggest an ex- 
planation why the patient passed for a 
time into a befogged or curiously muddled 
condition, or why he was even seized 
with convulsions — these alarming neurotic 
effects, as a rule, passing away with an 
increased renal discharge of bile-salts. 
Such patients are apt to be classed with the 
epileptics : and, but for the absence of the 
ordinary indications of Bright's disease, 
would doubtless be regarded as uraemic. 

I have been rather struck with the fact, 
that the urines of the cases of the cirr- 
hotic form of renal disease I have ex- 
amined showed a marked diminution in 
the proportion of biliary salts ; this variety 



250 BILE SALTS DIMINISHED. [Ch. XIII. 

of Bright's disease being, moreover, 
rather specially liable to retinal and other 
haemorrhages, and to uraemia. In a case 
of waxy kidney free from definite uraemic 
symptoms and from post mortem signs of 
uraemia, the urinary bile-salts were never 
below normal — in fact they were as a rule 
in considerable excess. 

If these observations should be confirmed 
by further enquiry, the question may 
arise : how far are the symptoms of 
uraemia referrible to cholaemia — the grave 
form of cholaemia that culmiminates in 
convulsions and coma.^ 



1 It is out of place in this work to discuss the pathology of 
urasmia. But without doing so, I may say, that all experi- 
mentation on animals up to the present has failed to definitely 
reveal the cause or causes of this condition : it has negatived 
all the following constituents of the urine — urea, kreatin, 
kreatinin, leucin, tyrosin, taurin, urates, hippurates. chlorides, 
sulphates, phosphates, extractives, ammonia salts (including 
the carbonate), and urinary ferment ; and the only evidence 
of a positive character which it adduces is in favour of the 
potash salts. The chemico-vital results of chronic Bright's 
disease are in all probability due to the retention of several 
chemical agents : for example, urea or its derivate, carbonate 
of ammonia, may excite the development of the muscular 
tissue of the circulatory organs (heart and arterioles); and the 
bile-salts may play an important role in inducing retinal and 
other haemorrhages (see p. 245), nausea, vomiting, diarrhaea, 
convulsions, coma, and death. 



CHAPTER XIV. 



APPARATUS. 



The mode of urinary testing described 
in the preceding pages requires for the 
efficient application of it a set of appara- 
tus, which, from its simplicity and com- 
pactness, is undoubtedly well adapted to 
the aim I have kept steadil}' in view : 
namely, to provide the most portable and 
easy methods for quickly determining the 
practical aspects of the urine in the 
course of work. 

I. Graduated Test Tubes : viz., 
(i). For determining the specific gravity 
(fig. i) by means of the glass head^ of the 
density of 1008 (fig. 5). 

1 The reliability of the method of ascertaining the specific 
gravity described in Chapter II. depends of course on the 
correctness of the density of the bead. This all-important 
point is indeed a matter of no small difficulty with the manu- 
facturer. Every bead sent out must he carefully tested and if 
needs be adjusted, by some thoroughly competent person. 
The Messrs. Wilson, of Harrogate, have undertaken to do 
this. 



Ch. XIV.] APPARATUS. 252 

(2) The tubes for uvine-testmg — qualitative 
and quantitative, 

(a) The short half-inch test tube (fig. 2) is 
used for the qualitative and quantitative 
observation of albumin, of glucose, of bile 
salts, and of the reaction of the urine. 
The lowest graduation measures oif 6onx. 
The fractions indicate the amount of 
albumin expressed as a deposit, when, on 
adding the albuminous urine, the lines 



placed behind the tube are no longer 
visible (see p. 133). 

(b) The flattened tube of determined diametus 
(not figured), graduated to 20onx, is used 
for the percentage estimation of albumin 
(see p. 134). 

II. — Standard Opacities. 

Experience has shown that the best 
form of permanent opacity is provided by 
alumina precipitated by ammonia : I, 
therefore, select it for the standards 



Ch.Xiv.j APPARATUS. 



253 



required for quantitative observation of 
albumin and bile-salts. 

1. The standard for quantitative albtimin. — 
The opaque fluid is sealed up in a short 
tube having the same diameters as those 
of the flattened graduated tube in which 
the estimation is made. Tne opalescence 
is that induced by the precipitation of -^ 
p. c. of serum albumin by the mercuric or 
ferrocyanic test. 

2. The standard for the quantitative observa- 
tion of bile-salts represents the average 
opacity produced by mixing together 
equal proportions (6oit|.) of the peptone 
test solution and normal urine reduced to 
the specific gravity of 1008. It is con- 
tained in a short round tube of the same 
diameter as of that used for testing. 

III. — Sundries. 

1. Nipple pipette (fig. 3). 

2. Metal clip (fig. 4) used as a tube 
holder during the boiling and heating 
required by the testing for sugar, and for 
drawing out the test-papers, &c. 

s 



254 . APPARATUS. [Ch. XIV. 

The whole of the apparatus for bedside 
observation can be conveniently packed 
up into a small compass. The pipette — 
the stem being pushed up within the 
rubber nipple — along with the clip is 
inserted into the small test tube, which 
fits into the stout tube containing the 
specific gravit}^ bead. 

IV. Test-Papers. 

Inasmuch as the preparation of the 
test-papers is all-important, it should be 
undertaken by some trustworth}^ person 
thoroughly conversant with all the neces- 
sary details that cannot be conveyed in 
print. Messrs. Wilson and Son, of Har- 
rogate, have hitherto supplied them to 
my satisfaction. 



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